Volume 14 Issue 4 Version 1.0

Online ISSN: 2249-4618 Print ISSN: 0975-5888

Evaluate the Effect Implant Surface Micro-Design Desquamative Gingivitis Estrogen Deficiency and Chronic

VOLUME 14 ISSUE 4 VERSION 1.0

Global Journal of Medical Research: J Dentistry and Otolaryngology

Global Journal of Medical Research: J Dentistry and Otolaryngology Volume 14 Issue 4 (Ver. 1.0)

Open Association of Research Society

© Global Journal of Medical Global Journals Inc. Research . 2014. (A Delaware USA Incorporation with “Good Standing”; Reg. Number: 0423089) Sponsors:Open Association of Research Society All rights reserved. Open Scientific Standards

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John A. Hamilton,"Drew" Jr., Dr. Wenying Feng Ph.D., Professor, Management Professor, Department of Computing & Computer Science and Software Information Systems Engineering Department of Mathematics Director, Information Assurance Trent University, Peterborough, Laboratory ON Canada K9J 7B8 Auburn University Dr. Thomas Wischgoll Dr. Henry Hexmoor Computer Science and Engineering, IEEE senior member since 2004 Wright State University, Dayton, Ohio Ph.D. Computer Science, University at B.S., M.S., Ph.D. Buffalo (University of Kaiserslautern) Department of Computer Science Southern Illinois University at Carbondale Dr. Abdurrahman Arslanyilmaz Dr. Osman Balci, Professor Computer Science & Information Systems Department of Computer Science Department Virginia Tech, Virginia University Youngstown State University Ph.D.and M.S.Syracuse University, Ph.D., Texas A&M University Syracuse, New York University of Missouri, Columbia M.S. and B.S. Bogazici University, Gazi University, Turkey Istanbul, Turkey Dr. Xiaohong He Professor of International Business Yogita Bajpai University of Quinnipiac M.Sc. (Computer Science), FICCT BS, Jilin Institute of Technology; MA, MS, U.S.A.Email: PhD,. (University of Texas-Dallas) [email protected] Burcin Becerik-Gerber Dr. T. David A. Forbes University of Southern California Associate Professor and Range Ph.D. in Civil Engineering Nutritionist DDes from Harvard University Ph.D. Edinburgh University - Animal M.S. from University of California, Berkeley Nutrition & Istanbul University M.S. Aberdeen University - Animal Nutrition B.A. University of Dublin- Zoology Dr. Bart Lambrecht Dr. Söhnke M. Bartram Director of Research in Accounting and Department of Accounting and FinanceProfessor of Finance FinanceLancaster University Management Lancaster University Management School SchoolPh.D. (WHU Koblenz) BA (Antwerp); MPhil, MA, PhD MBA/BBA (University of Saarbrücken) (Cambridge) Dr. Miguel Angel Ariño Dr. Carlos García Pont Professor of Decision Sciences Associate Professor of Marketing IESE Business School IESE Business School, University of Barcelona, Spain (Universidad de Navarra) Navarra CEIBS (China Europe International Business Doctor of Philosophy (Management), School). Massachusetts Institute of Technology Beijing, Shanghai and Shenzhen (MIT) Ph.D. in Mathematics Master in Business Administration, IESE, University of Barcelona University of Navarra BA in Mathematics (Licenciatura) Degree in Industrial Engineering, University of Barcelona Universitat Politècnica de Catalunya Philip G. Moscoso Dr. Fotini Labropulu Technology and Operations Management Mathematics - Luther College IESE Business School, University of Navarra University of ReginaPh.D., M.Sc. in Ph.D in Industrial Engineering and Mathematics Management, ETH Zurich B.A. (Honors) in Mathematics M.Sc. in Chemical Engineering, ETH Zurich University of Windso Dr. Sanjay Dixit, M.D. Dr. Lynn Lim Director, EP Laboratories, Philadelphia VA Reader in Business and Marketing Medical Center Roehampton University, London Cardiovascular Medicine - Cardiac BCom, PGDip, MBA (Distinction), PhD, Arrhythmia FHEA Univ of Penn School of Medicine

Dr. Mihaly Mezei Dr. Han-Xiang Deng ASSOCIATE PROFESSOR MD., Ph.D Department of Structural and Chemical Associate Professor and Research Biology, Mount Sinai School of Medical Department Division of Neuromuscular Center Medicine Ph.D., Etvs Lornd University Davee Department of Neurology and Clinical Postdoctoral Training, NeuroscienceNorthwestern University New York University Feinberg School of Medicine Dr. Pina C. Sanelli Dr. Michael R. Rudnick Associate Professor of Public Health M.D., FACP Weill Cornell Medical College Associate Professor of Medicine Associate Attending Radiologist Chief, Renal Electrolyte and NewYork-Presbyterian Hospital Hypertension Division (PMC) MRI, MRA, CT, and CTA Penn Medicine, University of Neuroradiology and Diagnostic Pennsylvania Radiology Presbyterian Medical Center, M.D., State University of New York at Philadelphia Buffalo,School of Medicine and Nephrology and Internal Medicine Biomedical Sciences Certified by the American Board of Internal Medicine

Dr. Roberto Sanchez

Associate Professor Dr. Bassey Benjamin Esu

Department of Structural and Chemical B.Sc. Marketing; MBA Marketing; Ph.D Biology Marketing Mount Sinai School of Medicine Lecturer, Department of Marketing, Ph.D., The Rockefeller University University of Calabar Tourism Consultant, Cross River State Tourism Development Department Dr. Wen-Yih Sun Co-ordinator , Sustainable Tourism Professor of Earth and Atmospheric Initiative, Calabar, Nigeria SciencesPurdue University Director

National Center for Typhoon and Dr. Aziz M. Barbar, Ph.D. Flooding Research, Taiwan IEEE Senior Member University Chair Professor Chairperson, Department of Computer Department of Atmospheric Sciences, Science National Central University, Chung-Li, AUST - American University of Science & TaiwanUniversity Chair Professor Technology Institute of Environmental Engineering, Alfred Naccash Avenue – Ashrafieh National Chiao Tung University, Hsin- chu, Taiwan.Ph.D., MS The University of Chicago, Geophysical Sciences BS National Taiwan University, Atmospheric Sciences Associate Professor of Radiology

President Editor (HON.) Dr. George Perry, (Neuroscientist) Dean and Professor, College of Sciences Denham Harman Research Award (American Aging Association) ISI Highly Cited Researcher, Iberoamerican Molecular Biology Organization AAAS Fellow, Correspondent Member of Spanish Royal Academy of Sciences University of Texas at San Antonio Postdoctoral Fellow (Department of Cell Biology) Baylor College of Medicine Houston, Texas, United States

Chief Author (HON.) Dr. R.K. Dixit M.Sc., Ph.D., FICCT Chief Author, India Email: [email protected]

Dean & Editor-in-Chief (HON.) Vivek Dubey(HON.) Er. Suyog Dixit MS (Industrial Engineering), (M. Tech), BE (HONS. in CSE), FICCT MS (Mechanical Engineering) SAP Certified Consultant University of Wisconsin, FICCT CEO at IOSRD, GAOR & OSS Technical Dean, Global Journals Inc. (US) Editor-in-Chief, USA Website: www.suyogdixit.com [email protected] Email:[email protected] Sangita Dixit Pritesh Rajvaidya M.Sc., FICCT (MS) Computer Science Department Dean & Chancellor (Asia Pacific) California State University [email protected] BE (Computer Science), FICCT Suyash Dixit Technical Dean, USA (B.E., Computer Science Engineering), FICCTT Email: [email protected] President, Web Administration and Luis Galárraga Development , CEO at IOSRD J!Research Project Leader COO at GAOR & OSS Saarbrücken, Germany

Contents of the Volume

i. Copyright Notice ii. Editorial Board Members iii. Chief Author and Dean iv. Table of Contents v. From the Chief Editor’s Desk vi. Research and Review Papers

1. Waveone and one Shape Files: Survival in Severely Curved Artificial Canals. 1-7 2. To Evaluate the Effect of Probiotic Mouthrinse on Plaque and Gingivitis among 15-16 Year Old School Children of Mysore City, India- Randomized Controlled Trial. 9-14 3. A 3- Year Evaluation of Anterior Open Bite Treatment Stability with Occlusal Adjustment. 15-22 4. Nonsurgical Management of Cutaneous Sinus Tract of Odontogenic Origin: A Case Report. 23-25 5. Correlation between Estrogen Deficiency and Chronic Desquamative Gingivitis in Female Patients. 27-34 6. Implant Surface Micro-Design. 35-51 7. Effect of Probe-Tip Placement on Impedance Audiometry. 53-56 8. A Method to Construct an Interim Obturator using Presurgical Tissues for Maxillary Palatal Defect . 57-59 vii. Auxiliary Memberships viii. Process of Submission of Research Paper ix. Preferred Author Guidelines x. Index

Global Journal of Medical Research: J Dentistry and Otolaryngology Volume 14 Issue 4 Version 1.0 Year 2014 Type: Double Blind Peer Reviewed International Research Journal Publisher: Global Journals Inc. (USA) Online ISSN: 2249-4618 & Print ISSN: 0975-5888

Waveone and one Shape Files: Survival in Severely Curved Artificial Canals By Emilia Karova & Snezhanka Topalova-Pirinska Faculty of Dental Medicine, Medical University, Bulgaria Abstract- Nickel-titanium rotary instruments are preferred for their excellent flexibility, superelasticity and improved cutting efficiency but they can separate unexpectedly, especially in curved canals. Instrumentation with WaveOne and One Shape files was performed on 200 artificial canals divided in four equal groups. Glide path was created with PathFiles and G-files. Average lifespan and survival rate of the shaping files were tested, before and after a glide path creation. Average lifespan of WaveOne and One Shape files without a creation of a glide path was 10.25±2.50 canals and 4.1 (±1.37) canals, respectively and after the creation of a glide path – 17.50±2.12 canals and 4.6 (±1.30) canals. Average lifespan and cumulative survival of the tested files revealed significant difference. WaveOne files showed significantly higher resistance to fracture compared with One Shape files. Lifespan and survival rate of tested files increased after the creation of a glide path. Reciprocal motion increases significantly instruments life.

Keywords: nickel-titanium instruments, waveone, one shape, pathfiles, g-files, glide path, lifespan, cumm-ulative survival, continuous rotation, reciprocating motion. GJMR-J Classification: NLMC Code: WV 1

WaveoneandoneShapeFilesSurvivalinSeverelyCurvedArtificialCanals

Strictly as per the compliance and regulations of:

© 2014. Emilia Karova & Snezhanka Topalova-Pirinska. This is a research/review paper, distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Waveone and one Shape Files: Survival in Severely Curved Artificial Canals

Emilia Karova α & Snezhanka Topalova-Pirinska σ

Abstract- Nickel-titanium rotary instruments are preferred for fatigue (Di Fiore, 2007; Wu et al., 2011). Root canal their excellent flexibility, superelasticity and improved cutting anatomy, instrument design, manufacturing process, efficiency but they can separate unexpectedly, especially in preparation technique and operator skill can affect the curved canals. Instrumentation with WaveOne and One Shape fracture mode and the fracture rate of these instruments files was performed on 200 artificial canals divided in four

(Parahos et al., 2004; Parashos et al., 2006; Shen et al., 2014 equal groups. Glide path was created with PathFiles and G- files. Average lifespan and survival rate of the shaping files 2009; Kim et al., 2010; Zhang et al., 2010). The chance were tested, before and after a glide path creation. Average of removing the broken file is very low in some cases Year and sometimes may be impossible without lifespan of WaveOne and One Shape files without a creation of 1 a glide path was 10.25±2.50 canals and 4.1 (±1.37) canals, compromising the endodontic treatment outcome respectively and after the creation of a glide path – (Hulsmann et al., 1999). 17.50±2.12 canals and 4.6 (±1.30) canals. Average lifespan To reduce the separation incidence, and cumulative survival of the tested files revealed significant manufacturers have developed new techniques to difference. WaveOne files showed significantly higher improve the physical and mechanical properties of their resistance to fracture compared with One Shape files. instruments. One important modification of the NiTi Lifespan and survival rate of tested files increased after the creation of a glide path. Reciprocal motion increases alloy, which makes rotary systems more flexible and significantly instruments life. more resistant to cyclic fatigue, and improves their Keywords: nickel-titanium instruments, waveone, one cutting efficiency, is the M-Wire alloy (Dentsply Tulsa shape, pathfiles, g-files, glide path, lifespan, cumm- Dental, Tulsa, OK) (Gambarini et al., 2008; Alapati et al., ulative survival, continuous rotation, reciprocating 2009; Lopes et al., 2013). M-Wire is a NiTi alloy motion. prepared by a special thermal process and is used in the production of WaveOne reciprocating files (Dentsply,

I. Introduction Tulsa Dental Specialties, Tulsa, OK). Volume XIV Issue IV Version I

Reciprocating mode of rotation has been ) J DD D echanical instrumentation and thorough D

introduced recently with the intent to extend the lifespan ( debridement of root canal space are essential of a NiTi instrument and its resistance to fatigue in prerequisites for successful endodontic M comparison with continuous rotation (De-Deus et al., treatment (Schilder, 1974; Hulsmann et al., 2005). 2010; Varela Patino et al., 2010; You et al., 2010; Franco Stainless steel files can be used for achieving this goal et al., 2011; Pedulla et al., 2013). WaveOne files are but recently nickel-titanium (NiTi) rotary instruments are Research used with specific motor with unchangeable settings. preferred for their excellent flexibility, superelasticity and The engine generates different angles of rotation - 170º improved cutting efficiency (Chen et al., 2002; Sonntag

counterclockwise and then 50º clockwise rotation with a Medical et al., 2003; Peters, 2004; Schäfer et al., 2004). These speed of 350 rpm – which affect the fatigue resistance instruments can minimize ledging and transportation, (Kim et al., 2012). The system consists of 3 sterile create more centered and rounded canal preparation single-use files with noncutting modified guiding tips: and for these reasons are frequently chosen for small (ISO 21 tip and 6% taper) for small canals, primary instrumentation of curved root canals (Short et al., 1997; (ISO 25 tip and 8% taper) for the majority of canals, and Bonaccorso et al., 2009; Cheung et al., 2009). Despite large (ISO 40 tip and 8% taper) for large canals. The last their undeniably favorable qualities, NiTi rotary two have fixed tapers of 8% from D1 to D3, whereas instruments can separate unexpectedly, especially when Global Journal of from D4 to D16, they have a unique progressively they are forced into the canal or are overused (Sattapan decreasing percentage tapered design. Thus, flexibility et al., 2000; Arens et al., 2003). Fractures of NiTi rotary is improved and the remaining dentin in the coronal two instruments are result of torsional stress or cyclic flexural thirds of the canal is preserved. Another unique design Author α : Department of Conservative Dentistry, Faculty of Dental features of the WaveOne files are the reverse helix and Medicine, Medical University, Sofia; 1, St. George Sofiiski blvd., 1431 the two distinct cross-sections along the length of their Sofia, Bulgaria. e-mail: [email protected] active portions (a modified convex triangular cross Author σ : Prof. Dr. Snezhanka Topalova-Pirinska, PhD, Department of section from D1 to D8 and a convex triangular cross Conservative Dentistry, Faculty of Dental Medicine, Medical University, Sofia; 1, St. George Sofiiski blvd., 1431 Sofia, Bulgaria. section from D9 to D16). The design of the two e-mail: [email protected] WaveOne cross sections is further enhanced by a

changing pitch and helical angle along their active The One Shape files were used with a rotation speed of portions (Webber et al., 2011). 400 rpm and torque 2.0gr/cm2. PathFiles and G-files One Shape rotary NiTi files (MicroMega) work worked at one and the same rotation speed (300 rpm) with continuous rotation and the producers try to and torque (0.6gr/cm2). The amount of pressure applied increase their flexibility and to reduce instrument to all files was the pressure that could be applied to a screwing effects by a variable cross-section along the sharp #2 pencil without breaking the lead. The files blade of the instrument. They have 3 different cross- were never forced into the canal. section zones: apical (with a variable 3-cutting-edge Initially, all canals were scouted to full working design), transitional (progressively changing from 3 to 2 length with a #10 hand K-file. In the first group all canals cutting edges) and coronal (with 2 cutting edges). Anti were shaped with the small (ISO 21 tip and 6% taper) Breakage Control (ABC) increases safety and avoids WaveOne file, following the instructions of the producer separation by unwinding of the instrument. The system (a #10 hand K-file to be very resistant to movement at consists of one sterile single file for root canal shaping the initial inspection of the root canals).

2014 (ISO 25 tip and 6% taper) with variable pitch and non- In the second group shaping was performed working (safety) tip. with One Shape files (ISO 25 tip and 6% taper). Year File distortion and breakage, especially in In the third group a glide path was created at the 2 severely curved canals, can be reduced or avoided not beginning with PathFile System. It consists of three only by improved design and mechanical properties of instruments with a square cross section, four cutting the instruments, but by manual preflaring of the root angles, 21-25-31 mm length, a 0.02 taper and a size of canal and creation of a glide path, as well. There is a the tip ISO 13, 16 and 19. Later, the canals were strong evidence in the literature (Roland et al., 2002; instrumented with the small (ISO 21 tip and 6% taper) Berruti et al., 2004; Varela-Patino et al., 2005; Zarrabi et WaveOne file. al., 2010) that fracture incidence might be reduced as a In the fourth group G-Files were used for glide result of the preliminary enlargement of the root canal path creation. G-Files consist of two instruments 21-25- diameter. Thus, the size of the canal becomes bigger 29 mm long, with a 0.03 taper, a size of the tip ISO 12 than or at least the same size as the tip of the first and 17 and a variable cross-section throughout the shaping rotary instrument used (Berruti et al., 2004; length of the instrument. The 3 cutting edges are on Varela-Patino et al., 2005). Hand-operated and engine- three different radiuses relative to the axis of the canal, driven instruments can be used for glide path creation. leaving a large and efficient area for upward debris Recently, two new rotary NiTi systems have been removal. Shaping was finished with One Shape files Volume XIV Issue IV Version I introduced for this purpose: PathFile System (Dentsply (ISO 25 tip and 6% taper).

J Maillefer) and G-Files (MicroMega). WaveOne and One Shape files worked till

() The aim of the present study was to compare fracture occurred. the survival of WaveOne and One Shape files used for During mechanical instrumentation each file the instrumentation of severely curved artificial canals, was coated with Glyde™ (Dentsply Maillefer) to act as a before and after the creation of a glide path. lubricant, and copious irrigation with 5.25% NaOCl was

Research carried out. II. Materials and Methods The instrumentation of all canals was performed by a Canal preparation was performed on 200 Endo- single operator. Medical Training Block simulators (Dentsply Maillefer) with an III. Results apical diameter of 0.15 and a 0.02 taper, a 65 degree curvature and a 7.5 mm curvature radius. a) Average Lifespan of Shaping Files The canals were divided in four equal groups: i. Comparison between WaveOne and One Shape 1st group – shaped with WaveOne (Dentsply Maillefer) files reciprocating files; 2nd group – shaped with One Shape Fifteen files were used in canals’ preparation (Micro Mega) files; 3rd group – preflared with PathFile and fourteen of them broke: 4 WaveOne files and 10 Global Journal of System (Dentsply Maillefer) and shaped with WaveOne One Shape files. The longest lifespan of a single files; 4th group – preflared with G-Files (Micro Mega) and WaveOne file was 13 canals and of a single One Shape shaped with One Shape files. file - 7 canals. Respectively, the shortest lifespan was 7 Average lifespan and cumulative survival at the and 2 canals. time of WaveOne and One Shape files were tested, The average lifespan of one WaveOne file was before and after a glide path creation. 10.25±2.50 canals and of a single One Shape file - Following the instructions of the producer all 4.1±1.37 canals. The difference was statistically files were operated using The WaveOne™ Endodontic significant (p<0.001) (t-test). system (Dentsply Maillefer), which is pre-programmed ii. Comparison between WaveOne and with settings for the WaveOne reciprocating file system. WaveOne+PathFiles

Eight WaveOne reciprocating files were used in The average lifespan of a single One Shape file canals’ preparation and six of them broke: 4 files before without a creation of a glide path was 4.1 (±1.37) canals the creation of a glide path and 2 after the initial and after a creation of a glide path – 4.6 (±1.30) canals. enlargement of the artificial canals with PathFile System. The difference was statistically insignificant (р>0.05) (t- The longest lifespan of a single file from the first group test). was 13 canals and from the second group – 19 canals. iv. Comparison between WaveOne+PathFiles and The shortest lifespan was measured in the first group One Shape+G-Files and was 7 canals. Twelve shaping files were used after the initial The average lifespan of one WaveOne file enlargement of the canals – 3 WaveOne files and 9 One without a creation of a glide path was 10.25±2.50 Shape files. During the instrumentation ten of them canals and after a creation of a glide path – 17.50±2.12 broke: 2 WaveOne files and 8 One Shape files. The canals. The difference was statistically significant longest lifespan of a single file from the first group was (p<0.05) (t-test). 19 canals and from the second group – 6 canals. The iii. Comparison between One Shape and One shortest lifespan was measured in the second group 2014 Shape+G-Files

and was only 2 canals. Year Nineteen files were used during the After the creation of a glide path, the average instrumentation and 18 of them broke: 10 in the group lifespan of one WaveOne file was 17.50±2.12 canals 3 without a glide path and 8 – after the preliminary and of a single One Shape file–4.63±1.30 canals. The enlargement with G-Files. The longest lifespan in the first difference was statistically significant (p<0.001) (t-test). group is 7 canals and in the second – 6 canals. Two The results of the average lifespan of the tested shaping canals were the shortest lifespan in both groups. files can be summarized in Table 1.

Table 1 : Average lifespan of WaveOne and One Shape rotary files Highest number of Lowest number of Number of № Preparation technique successfully treated successfully treated Average broken files canals canals lifespan

1 WaveOne 4 13 7 10.25±2.50 2 WaveOne+PathFile 2 19 16 17.50±2.12 Volume XIV Issue IV Version I 3 One Shape 10 7 2 4.1 (±1.37) ) J DD D D

4 One Shape+G-Files 8 6 2 4.63±1.30 ( b) Cumulative Survival at the Time of Shaping Files the cumulative survival of one WaveOne file was 100%, The survival rate for one WaveOne files was while it was only 10% for a single One Shape file. At the 75% at the instrumentation of the 8th canal, 50% at the 8th canal 75% of WaveOne files were intact but all One Research 11th one and 25% at the shaping of the twelve canal. Shape files were broken.

The cumulative proportion surviving at the time ii. Comparison between WaveOne and rd for One Shape was 90% at the instrumentation of the 3 WaveOne+PathFiles Medical th th canal, 70% at the 4 one, 30% at the 5 and 10% at the After the creation of a glide path, all WaveOne 6th canal. All files were broken at the preparation of the th Files were intact (100% survival) at the instrumentation 8 canal. of the 14th canal, while all of them from the first group The cumulative survival for WaveOne files, after (without a glide path) were broken. The log-rank test the creation of a glide path, was 50% at the presented a significantly longer survival (р<0.05) for the instrumentation of the 17th canal and all files were th instruments used after a glide path was created. separated at the instrumentation of the 20 canal. Global Journal of The survival rate for One Shape files, after the iii. Comparison between One Shape and One creation of a glide path, was 88.9% at the Shape+G-Files instrumentation of the 3rd canal, 66.7% at the At the shaping of the 5th canal, after the instrumentation of the 5th canal, 26.7% at the preparation creation of a glide path, the cumulative survival of a of the 6th canal and all files were separated at the single One Shape file (66.7%) was twice as high as in instrumentation of the 7th canal. the first group (30%). i. Comparison between Although the survival rate increased after the WaveOne and One Shape files preliminary enlargement of the canal diameter, the The comparison between the two systems difference between the two groups remained reveals significant difference (р <0.05). At the 6th canal insignificant (р>0.05).

path, the log-rank test presented a significantly longer iv. Comparison between WaveOne+PathFiles and One Shape+G- Files survival for the WaveOne instruments when compared When comparing the results from both groups, with the One Shape files (р<0.05). it is found that at the instrumentation of the 7th canal all The survival curves of the tested instruments are WaveOne files were intact (100% survival), while all One presented on Fig. 1. Shape files were broken. After the creation of a glide

2014 Year

Figurer 1 : Survival curves of WaveOne and One Shape files

IV. Discussion fracture and can break at a lower cyclic fatigue (Cheung et al., 2005), and at the same time, torsional resistance Volume XIV Issue IV Version I Our study was carried out on standardized decreases in used files (Parashos et al., 2006).

J artificial canals, which are expected to minimize the The observations in our study are similar to the () influence of other variables (Yao et al., 2006). We used findings in the works of Pruett et al., Varela Patino et al. Endo-Training Block simulators with high degree and Tygesen et al. (Pruett et al., 1997; Tygesen et al., curvature in the apical 1/3 because we wanted to trace 2001; Varela Patino et al ., 2005). Instrument breakage out and to compare the survival of WaveOne and One occurred in the apical portion of the canal, a few

Research Shape rotary files under the conditions of greater stress. millimeters from the tip of the file, at the point of It is well documented in in vitro investigations that a maximum flexure within the canal, where the stress is stronger curvature and a smaller radius of the root canal greatest. Medical increase the risk of rotary instrument fracture (Pruett et The choice of the instruments compared in our al., 1997; Zelada et al., 2002; Martin et al., 2003). investigation was not accidental. Our attention was Despite the proven beneficial characteristics of the directed to WaveOne and One Shape NiTi rotary files nickel-titanium rotary instruments, the risk of their because they are sterile single-file systems and have separation, especially during the instrumentation of non-working (safety) tip and variable cross -sections severely curved canals is higher (Iqbal et al., 2006; You along the blade of the instrument. At the same time, they et al., 2010; Setzer et al., 2013). Fracture of NiTi files is a work with different mode of rotation – reciprocating

Global Journal of result of flexural and torsional failure. Flexural fracture is (WaveOne) and continuous (One Shape). Both

due to repeated compression and tension in curved producers claim their products are safe and ensure an canals that lead to cyclic flexural fatigue of the metal effective apical progression with low risk of fractures and and the initiation of cracks from the outer surface of the obstructions. In fact, the incidence of their separation in instrument (Berutti et al., 2006). In majority of cases, clinical practice can increase as s result of overusage

torsional fracture occurs in the last millimeters of the file due to their high cost.

when the tip or any other part of the instrument binds to The examined files have different size of the tip the canal walls whereas the handpiece keeps turning because of two reasons: firstly, the One Shape files are (Sattapan et al., B 2000; Arens et al., 2003; Di Fiore, offered only in one size and secondly, the tip size of the 2007; Varela Patino et al., 2010). Consequently, NiTi files WaveOne file was chosen strictly following the exposed to torsional stress are more susceptible to instructions of the manufacturer - to use the small

WaveOne file, if #10 hand K-file doesn’t easily move fast use even in severely curved and/or calcified canals. toward the terminus of the canal. The last files used from the two systems have different Sometimes, shaping of severely curved canals tip size (PathFile – ISO 19 and G-Files – ISO 17) and is a big challenge. That is the reason most clinical create different apical size of the canal. For the guidelines and manufacturers’ recommendations for WaveOne group it is closer to the size (ISO 21) of the instrumentation with rotary NiTi instruments to claim shaping file used when compared with the One Shape reduction of canal curvature. It can be achieved either group (ISO 25). Consequently, under one and the same by creating straight-line access, which is not always conditions, the stress accumulated on One Shape files possible, or by initial enlargement of the canal. The is greater and the separation incidence increases. preliminary creation of a glide path can be regarded as The great number of uses of WaveOne files can a crucial step during chemomechanical endodontic be attributed not only to the creation of a glide path but procedures which reduces the interference of the to the specific reciprocal way of rotation and their shaping instrument with canal walls and makes the design, as well. It is well documented that the subsequent use of the larger rotary NiTi instruments reciprocating rotation decreases the impact of cyclic 2014 safer and more effective (Roland et al., DD, 2002; fatigue on nickel-titanium rotary instrument life and the Ruddle, 2005; Di Fiore, 2007; Peters et al., 2010). The incidence of instrument fractures (in resin blocks and Year probability of canal modifications and aberrations natural teeth) is lower (Varela-Patino et al., 2008; Varela- 5 seems to be significantly reduced (Berruti et al., 2004; Patino et al., 2010; You et al., 2010; Pedulla et al., 2103). Varela Patino et al., 2005; Berruti et al., 2012). The survival of an instrument is directly proportional to The role of the initial creation of glide path is the stress accumulated during work in the root canal clearly demonstrated in our investigation, as well. After (Berutti et al., 2003). the preliminary enlargement of the artificial canals the In the couple WaveOne-One Shape a average lifespan and the cumulative survival of statistically significant difference between the average WaveOne and One Shape files were increased. lifespan of the two groups was found out. For one In the couple WaveOne-WaveOne+PathFiles WaveOne file it was 10.25±2.50 canals and for a single the difference between the average lifespan in the two One Shape file – only 4.1±1.37 canals. The tendency is groups was statistically significant (p<0.05). From preserved when the comparison was made after the 10.25±2.50 canals it raised to 17.50±2.12 canals, the creation of a glide path. The average lifespan of one number of broken files in the second group decreased WaveOne file was 17.50±2.12 canals and of a single twice and the highest lifespan values were found here – One Shape file –4.63±1.30 canals and again the 16 and 19 canals. The log-rank test presented a difference was statistically significant (p<0.001). Volume XIV Issue IV Version I )

The results from the cumulative survival are J DD D significantly longer survival (р<0.05) for the instruments D used after a glide path was created. In this group all similar. The comparison between the two systems ( WaveOne files were intact at the instrumentation of the reveals a huge difference. In the couple WaveOne-One 14th Shape 75% of WaveOne files were intact at the shaping canal while all the files from the first group were th broken; 50% of the instruments remained safe at the of the 8 canal while all One Shape files were broken.

th When a glide path was created, all One Shape files were Research shaping of the 17 canal and the files didn’t break until th the preparation of the 20th canal. separated at the instrumentation of the 7 canal but 100% of WaveOne files survived. The couple One Shape-One Shape+G-Files The findings from our study undoubtedly Medical reveals the same tendency. The average lifespan was demonstrate that reciprocating motion reduces torsional increased from 4.1 (±1.37) to 4.6 (±1.30) canals after stress and avoids taper-lock due to the unsymmetrical the creation of a glide path but the difference was repeating of the clockwise and counterclockwise insignificant ( >0.05). We found the greatest number of р rotations (Yared et al., 2001; You et al., 2010). Our fractures in the study – 10 and 8 files, respectively and results are in agreement with the findings of the work of the shortest lifespan of only two uses. At the Varela Patino et al. (Varela Patino et al., 2010) in which instrumentation of the 5th canal in the second group the

the incidence of instrument fracture in blocks of resin Global Journal of cumulative survival of a single One Shape file (66.7%) was lower with alternating rotation than with continuous was twice as high as in the first group (30%) but the rotation. The mean number of uses in their study was 10 difference between the two groups remained with alternating movement compared with 4-5 uses with insignificant (р>0.05). continuous rotation. Torsional stress is additionally The great difference in the results obtained for decreased when a glide path is initially created because WaveOne and One Shape files can be explained to the area on which the stress is exerted on is shifted from some extent with the characteristics of the two NiTi the tip of the file to its body. Reciprocating motion raises rotary systems used for glide path creation. They are our expectations for longer survival of the files and gives claimed by the producers to create a good combination us more comfort and safety, especially during shaping of flexibility, strength and efficacy that allows a safe and of severely curved root canals.

V. Conclusion 11. De-Deus G, Moreira EJ, Lopes HP, Elias CN. Extended cyclic fatigue life of F2 ProTaper In conclusion, within the limitations of this study, instruments used in reciprocating movement. Int WaveOne files showed significantly higher resistance to Endod J. 2010 Dec;43(12):1063-8. fracture compared with One Shape files. Instrumentation 12. Di Fiore PM. A dozen ways to prevent nickel- with files with reciprocal motion increases significantly titanium rotary instrument fracture. J Am Dent Assoc instruments life and makes them safer during shaping of 2007; 138: 196-201. root canals. NiTi rotary instruments can be used for creation of a glide path as a result of which the lifespan 13. Franco V, Fabiani C, Taschieri S, Malentacca A, Bortolin M, Del Fabbro M. Investigation of the and survival rate of WaveOne and One Shape files increase. shaping ability of nickel-titanium files when used with a reciprocating motion. J Endod 2011 VI. Acknowledgement Oct;37(10):1398-401.

14. Gambarini G, Grande NM, Plotino G, Somma F, 2014 The study is sponsored by the Scientific Council Garala M, De Luca M, et al. Fatigue resistance of of Medical University, Sofia, Bulgaria.

Year engine-driven rotary nickel-titanium instruments References Références Referencias produced by new manufacturing methods. J Endod 6 2008 Aug; 34(8):1003-5.

1. Alapati SB, Brantley WA, Iijima M, Clark WA, Kovarik 15. Hulsmann M, Peters OA, Dummer P. Mechanical

L, Buie C, et al. Metallurgical characterization of a preparation of root canals: shaping goals, new nickel-titanium wire for rotary endodontic techniques and means. Endod Topics 2005; 10: 30- instruments. J Endod 2009 Nov;35(11):1589-93. 76. 2. Arens FC, Hoen MM, Steiman HR, Dietz GC Jr. 16. Hulsmann M, Schinkel I. Influence of several factors Evaluation of single-use rotary nickel-titanium on the success or failure of removal of fractured instruments. J Endod. 2003 Oct;29(10):664-6. instruments from the root canal. Endod Dent 3. Berruti E, Negro AR, Lendini M, Pasqualini D. Traumatol 1999 Dec;15(6):252-8. Influence of manual preflaring and torque on the failure rate of ProTaper rotary instruments. J Endod 17. Iqbal MK, Kohli MR, Kim JS. A retrospective clinical study of incidence of root canal instrument 2004 Apr;30(4):228-30. 4. Berruti E, Paolino DS, Chiandussi G, et al. Root separation in an endodontics graduate programme: canal anatomy preservation of WaveOne A PennEndo database study. J Endod 2006; 32: Volume XIV Issue IV Version I reciprocating files with and without glide path. J 1048-52.

J Endod 2012; 38: 101-4. 18. Kim HC, Kwak SW, Cheung GS, Ko DH, Chung SM, () 5. Berutti E, Cantatore G. Rotary instruments in Nickel Lee W. Cyclic fatigue and torsional resistance of two Titanium. In: Castellucci A. Endodontics Vol.1. Ed. Il new nickel-titanium instruments used in Tridente Florence 2006: 518-547. reciprocation motion: Recoproc versus WaveOne. J 6. Berutti E, Chiandussi G, Gaviglio I, Ibba A: Endod. 2012 Apr;38(4):541-4.

Research Comparative analysis of torsional and bending 19. Kim HC, Yum J, Hur B, Cheung GS. Cyclic fatigue stresses in two mathematical models of nickel and fracture characteristics of ground and twisted titanium rotary instruments: ProTaper versus ProFile. nickel-titanium rotary files. J Endod 2010; 36: 147- Medical J Endodon 2003; 1 (29): 15-19. 52. 7. Bonaccorso A, Cantatore G, Condorelli GG, Schafer 20. Lopes HP, Gambarra-Soares T, Elias CN, Siqueira

E, Tripi TR. Shaping ability of four nickel-titanium JF Jr, Inojosa IF, Lopes WS, et al. Comparison of

rotary instruments in simulated S-shaped canals. J the mechanical properties of rotary instruments Endod 2009; 35: 883-6. made of conventional nickel-titanium wire, M-Wire, or nickel-titanium alloy in R-phase. J Endod 2013, 8. Chen JL, Messer HH. A comparison of stainless steel hand and rotary nickel-titanium instrumentation Apr;39(4):516-520.

Global Journal of using a silicone impression technique Aust Dent J 21. Martin B, Zelada G, Varela P, et al. Factors influencing the fracture of nickel-titanium rotary 2002; 47: 12-20. 9. Cheung GS, Liu CS. A restrospective study of instruments. J Endod 2003; 36: 262-6.

endodontic treatment outcome between nickel- 22. Parahos P, Gordon I, Messer HH. Factors titanium rotary and stainless steel hand filing influencing defects of rotary nickel-titanium techniques. J Endod 2009; 35: 938-43. endodontic instruments after clinical use. J Endod

10. Cheung GS, Peng B, Bian Z, Shen Y, Darvell BW. 2004; 30: 722-5.

Defects in ProTaper S1 instruments after clinical 23. Parashos P, Messer HH. Rotary NiTi instrument use: fractographic examination. Int Endod J. 2005 fracture and its consequences. J Endod 2006 Nov;38(11): 802-809. Nov;32(11):1031-43.

24. Pedulla E, Grande NM, Plotino G, Gambarini G, Alternating versus continuous rotation: A Rapisarda E. Influence of continuous or comparative study of the effect on instrument life. J reciprocating motion on cyclic fatigue resistance of Endod 2010 Jan; 36 (1):157-9. 4 different nickel-titanium rotary instruments. J 40. Varela-Patino P, Martin B, Rodrigues NJ, et al. Enodod. 2013 Feb;39(2): 258-261. Fracture rate of nickel-titanium instruments using 25. Peters OA, Peters CI. Cleaning and shaping of the continuous versus alternating rotation. Endodontic root canal system. In: Hargreaves KM, Cohen S, practice Today 2008; 2: 193-7. eds. Cohen’s Pathways of the Pulp, 10th ed. St. 41. Webber J, Machtou P, Pertot W, Kuttler S, Ruddle C, Louis, MO, Mosby; 2010: 283-348. West J. The WaveOne single -file reciprocating 26. Peters OA. Current challenges and concepts in the system. Roots. 2011; 1:28-33. preparation of root canal systems: a review. J 42. Wu J, Lei G, Yan M, Yu Y, Yu J, Zhang G. Instrument Endod 2004 Aug; 30 (8):559-567. separation analysis of multi-used ProTaper 27. Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue Universal Rotary System during root canal therapy. testing of nickel-titanium endodontic instruments. J J Endod 2011 Jun; 37(6):758 -763 . 2014 Endod 1997; 23: 77-85. 43. Yao JH, Schwartz SA, Beeson TJ. Cyclic fatigue of 28. Roland DD, Andelin WE, Browning DF, Hsu G-HR, three types of rotary nickel-titanium files in a Year Torabinejad M. The effect of preflaring on the rates dynamic model. J Endod 2006; 32: 55-7. 7 of separation for 0.04 taper nickel titanium rotary 44. Yared GM, Bou Dagher FE, Machtou P. Influence of instruments. J Endod 2002 Jul; 28 (7):543-545. rotational speed, torque, and operator’s proficiency 29. Ruddle CJ. The ProTaper technique. Endod Topics on ProFile failures. Int Endod J 2001; 34: 47-53. 2005; 10: 187-90. 45. You SY, Bae KS, Baek SH, Kum KY, Shon WJ,Lee 30. Sattapan B, Nervo GJ, Palamara JE, Messer HH. W. Lifespan of one nickel-titanium rotary file with Defects in rotary nickel-titanium files after clinical reciprocating motion in curved root canals. J Endod use. J Endod 2000; 26: 161-5. 2010 Dec; 36 (12):1991-94. 31. Schäfer E, Schulz-Bongert U, Tulus G. Comparison 46. Zarrabi MH, Javidi M, Vatanpour M, Esmaeili H. The of Hand Stainless Steel and Nickel Titanium Rotary influence of torque and manual glide path on the Instrumentation: A Clinical Study. J Endod 2004; 30 defect or separation rate of NiTi rotary instruments (6): 432-435. in root canal therapy. Indian J Dent Res 32. Schilder H. Cleaning and shaping the root canal. 2010;21:107-11. Dent Clin Nort h Am. 1974 Apr;18(2): 269-96. 47. Zelada G, Varela P, Martin B, et al. The effect of 33. Setzer FC, Bombe CP. Influence of combined cyclic rotational speed and the curvature of root canals on Volume XIV Issue IV Version I ) J DD D fatigue and torsional stress on the fracture point of the breakage of rotary endodontic instruments. J D

nickel-titanium rotary instruments. J Endod 2013; Endod 2002; 28: 540-2. ( 39: 133-137. 48. Zhang EW, Cheung GS, Zheng YF. Influence of 34. Shen Y, Haapasalo M, Cheug GS, Peng B. Defects cross-sectional design and dimension on in nickel-titanium instruments after clinical use. Part mechanical behavior of nickel-titanium instruments

I: relationship between observed imperfections and under torsion and bending: a numerical analyses. J Research factors leading to such defects in a cohort study. J Endod 2010; 36: 1394-8. endod 2009; 35: 129-32.

35. Short JA, Morgan LA, Baumgartner JC. A Medical comparison of canal centering ability of four instrumentation techniques. J Endod 1997; 23: 503- 7. 36. Sonntag D, Guntermann A, Kim SK, Stachniss V. Root canal shaping with manual stainless steel files and rotary NiTi files performed by students. Int

Endod J, 2003; 36: 246-255. Global Journal of 37. Tygesen YA, Steiman R, Ciavarro C. Comparison of distortion and separation utilizing ProFile and Pow-R nickel-titanium rotary files. J Endod 2001; 27: 762-4. 38. Varela Patino P, Biedma B, Rodriguez CL, Cantatore G, Bahillo JC. The Influence of a Manual Glide Path on the Separation Rate of NiTi Rotary Instruments. J Endodon 2005; 31 (2):114-116. 39. Varela Patino P, Ibanez-Parraga A, Rivas-Mundina B, Cantatore G, Otero XL, Martin-Biedma B.

2014 Year

This page is intentionally left blank Volume XIV Issue IV Version I J () Research Medical Global Journal of

To Evaluate the Effect of Probiotic Mouthrinse on Plaque and Gingivitis among 15-16 Year Old School Children of Mysore City, India- Randomized Controlled Trial By Dr. Sandhya Purunaik, Dr. Thippeswamy H M & Dr. Shrinivas Shripathrao Chavan

Abstract- Introduction: Probiotic concept of using beneficial bacteria has recently gained popularity in medical research. New methods such as probiotics has given a new dimension for both general and oral health.

Objectives: This study aimed to investigate the efficacy of a Probiotic mouthrinse in reducing plaque and gingivitis among schoolchildren aged 15-16 years.

Methods: This was a randomized, controlled, double blind clinical trial. 90 subjects granting their parental informed consent and willing to participate completed the trial. The sample was randomized by computer generated table into Group A –0.2% of chlorhexidine mouthrinse, Group B – Probiotic mouthrinse, Group C – Placebo mouthrinse. Products were masked as regards color. Intervention protocol consisted in supervised rinsing of 20 mL/day for 60 seconds twice daily for 14 days. Plaque and gingival indexes were used to assess the efficacy variables, measured at baseline and after intervention by calibrated examiner. Data were statistically analysed.

GJMR-J Classification: NLMC Code: WC 195, WN 230

ToEvaluatetheEffectofProbioticMouthrinseonPlaqueandGingivitisamong15-16YearOldSchoolChildrenofMysoreCityIndia-RandomizedControlledTrial

Strictly as per the compliance and regulations of:

© 2014. Dr. Sandhya Purunaik, Dr. Thippeswamy H M & Dr. Shrinivas Shripathrao Chavan. This is a research/review paper, distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License http:// creativecommons. org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

To Evaluate the Effect of Probiotic Mouthrinse on Plaque and Gingivitis among 15-16 Year Old School Children of Mysore City, India- Randomized Controlled Trial

Dr. Sandhya Purunaik α, Dr. Thippeswamy H M σ & Dr. Shrinivas Shripathrao Chavan ρ 2014 Abstract- Introduction: Probiotic concept of using beneficial from the teeth. These live together within a biofilm com- bacteria has recently gained popularity in medical research. munity through the exploitation of very specific ecologi- Year New methods such as probiotics has given a new dimension cal niches1. for both general and oral health. 9 Dental disease such as dental caries and Objectives: This study aimed to investigate the efficacy of a periodontal disease remains a “silent epidemic” in the Probiotic mouthrinse in reducing plaque and gingivitis among schoolchildren aged 15-16 years. world that threatens children and adults. The oral streptococci especially mutans streptococci are related Methods: This was a randomized, controlled, double blind with the development of caries. The adhesion of oral clinical trial. 90 subjects granting their parental informed consent and willing to participate completed the trial. The streptococci such as Streptococcus mutansto tooth sample was randomized by computer generated table into surfaces has the major role in their pathogenicity. Going Group A –0.2% of chlorhexidine mouthrinse, Group B – along with the increasing antibiotic resistance of Probiotic mouthrinse, Group C – Placebo mouthrinse. bacteria, new methods such as whole bacteria Products were masked as regards color. Intervention protocol replacement therapy for decreasing of oral cavity consisted in supervised rinsing of 20 mL/day for 60 seconds 2 pathogens must be investigated. twice daily for 14 days. Plaque and gingival indexes were used The mere spell of the word microorganism often to assess the efficacy variables, measured at baseline and after intervention by calibrated examiner. Data were statistically gives a threat of health hazard. But, friendly microorganisms called Probiotics have changed this Volume XIV Issue IV Version I

analysed. ) J DD D concept and have given a new dimension for both D

Results: It was found that both Probiotic and chlorhexidine 3 ( mouthrinses were able to significantly reduce plaque and general and oral health gingival levels after 14 days (p<0.05). The definition of “probiotics” has been adopted Conclusion: probiotic mouthrinse showed significant reduction by the International Scientific Association and the World in plaque score and gingival level. Health Organization: “Live microorganisms, if

administered in adequate amounts, confer a health Research 1. Gingivitis has been largely distributed among 4 children and adults. Hence, it becomes important to benefit on the host” consider alternatives for better oral health care. The basic rationale behind the tautology of Medical 2. A new possibility; to control plaque and gingivitis probiotics was that the human body lives in a heavily levels by means of a natural product that seems to contaminated environment associated with millions of overcome adverse effects of chlorhexidine bacteria and probiotics can be utilised by replacing mouthrinse such as altered taste and tooth staining pathogenic microorganisms with healthy ones. This is provided. concept of using beneficial bacteria has gained much 3. The product investigated was proven to be efficient popularity in the field of medical research in recent years and safe in a 14-day treatment. Also, it was well where antibiotic resistance is an increasing global

5 Global Journal of accepted by study participants. problem The first species introduced into research were I. Introduction Lactobacillus acidophilus and Bifidobacteriumbifidum , ore than 1000 bacterial species have been and among a number of potential benefits that have identified from the human mouth. These been proposed are reduced susceptibility to infections , Mmicroorganisms are easily grown and produce reductions to allergies and lactose intolerance, as well dental plaque in the mouth environment, due to the as lowered blood pressure and serum cholesterol considered as a microbiota consisting on average of values.Within dentistry, previous studies with lactobacilli more than 400 species in each gram of plaque removed strains such as L.rhamnosus , L. acidophilus and L. casei, L.reuteri or a lactobacilli mix have revealed mixed Author : e-mail: [email protected] results on oral microorganisms.6

To our knowledge in India, none of these according to treatment groups after Baseline formulations are readily available for oral health, so there examination into : exists a need to explore easily available alternative Group A – 0.2% of CHX mouthrinse approach to bacterial mediated oral disease such as Group B – Probiotic mouthrinse gingivitis. Group C – Placebo mouthrinse Hence this study was undertaken to test the The subjects and the examiner were hypothesis that Short term administration of blinded regarding the product allocation.Knowledge probioticmouth rinse is effective in reducing plaque and of the randomization list obtained by computer gingivitis generated table was limited to the study coordinator. II. Materials and Methods d) Preparation of Mouthrinses a) Samp le size calculation JSS University pharmacy prepared the This study is a double blind Randomized 2014 mouthrinses in undistinguishable packets and sent them

controlled trial and powered to evaluate the effect of to the study coordinator, who marked the code number

Year probiotic mouth rinse on plaque and gingivitis.From a of each subject on the packets, according to the therapy review of key papers the ideal sample size toassure 10 assigned and gave them to the examiner. The random adequate power for that Randomized Controlled Trial allocation sequence was generated by the clinical

was calculated considering potential mean difference of investigator.To maintain full blinding of the results , the 1.5 between control and test groups for the difference randomization table was held by the study coordinator between subject values on Quigley Hein Plaque index. It remotely from all the assessment and was not broken was determined that 30 subjects pergroup would be until the data was collected and analysed. The necessary to provide80% power with an α of 0.05. randomization was concealed by using sequentially i. Subject population, inclusion and exclusion numbered ; identical appearing containers to subject

criteria assigned treatment. The mouthrinses were decoded Subjects were selected from the populationby after the data was analysed. simple random sampling. In brief, the 90 eligible Probiotic product: probiotic mouthrinse was prepared by subjects were thoroughlyinformed of the nature, using commertially available probiotic product Darolac ( potentialrisks and benefits of their participationin the Aristo pharmaceuticals, india) containing 1 gm powder study and signed a termof Informed Consent. of 1.25 billion freeze dried combination , it comprised of Volume XIV Issue IV Version I b) The inclusion criteria were as follows a mixture of , Lactobacillus acidophilus, lactobacillus J • School children between 15-16 years of age as rhamnosus, bifidobacteriumlongum, and () per school records. Saccharomyces boulardii .Each sachet powder was • School children willing to participate. dissolved in 20ml of water in a measuring cup and used 5 • School children with parental consent as a mouth rinse .The placebo mouthrinse was • School children with no recent antibiotic prepared using distilled water. Research Chlorhexidinegluconate mouthwash (Proprietary therapy(within 4 weeks) name: Clohex, concentration 0.2%) was procured from c) The exclusion criteria were as follows the market and given to the pharmacy manufacturing Medical • Children undergoing orthodontic treatment center. It was then diluted and the final concentration of

• Children suffering from any systemic illness. Chlorhexidinegluconate was 0.2% such that 20 ml was • Children using any other commercially available dispensed at one time. Both solutions were made of mouth rinse or probiotic products. identical colors to eliminate bias • Children using any other oral hygiene aids other Investigators calibration: The examiner participated in than routine teeth brushing. calibration exercise that was performed by taking • Children with mixed dentition measurement in duplicate at randomly chosen teeth in Global Journal of A complete clinical oral assessment of all subjects who were not included in the study. Calibration subjects was carried out based on inclusion and was accepted when the results were identical on >85% exclusion criteria for selection of study subjects. of occasions ii. Experimental design, allocation concealment Treatment protocol : when the subjects volunteered for The medical and dental records of all subjects the study and before they received a packet containing were recorded by a questionnaire. mouthrinses and instruction for use, baselineplaque In this double blinded randomized placebo index Tureskey modification of Quigley & Hein Plaque controlled clinical trial , subjects were enrolled and index(QHI)7 and gingival index 8(Loe H. and Silness P., assigned to a computer generated table by the 1963) were recorded by clinical examination. Gingivitis examiner who assigned the coded mouthrinses of the buccal and lingual marginal gingiva and

© 2014 Global Journals Inc. (US) To Evaluate the Effect of Probiotic Mouthrinse on Plaque and Gingivitis among 15-16 Year Old School Children of Mysore City, India- Randomized Controlled Trial interdentalpapillae of all scorable teeth wasscored using the subjects to return the old packets containing the Loe–Silness Gingival Index(Loe&Silness 1963) in mouthrinses and received a new packets of which thegingivae are scored on a four-pointscale from mouthrinses. The single examiner was responsible for 0 (absence of inflammation) to 3 (severe- inflammation). conducting the enquiry on adverse events and also Supragingival plaque was scored onthe buccal and monitoring of compliance During the study period no lingual surfaces of allscorable teeth using the dropouts and withdrawals were encountered. Tureskymodification of the Quigley–HeinPlaqueIndex Primary outcome variables: All clinical measurements (Turesky et al. 1970).Following disclosing with an were obtained in all subjects at baseline and 14 day. It erythrosine solution, plaque was scored on a six-point was defined that the primary outcome variable to scale from 0 (no plaque) to 5 (plaque covers two thirds determine the superiority of one treatment over the other or more of the tooth surface). would be differences between groups in the reduction of Each subject was given one of the test products plaque and gingival index compared from baseline to with a given code according to the assigned group. 20 follow up. 2014 ml of mouth rinse was dispensed for each individual Statistical analysis: The significance of difference within

using a measuring cup & subjects were instructed to each group (over the course of study) was sought using Year swish the mouth rinse for 60 seconds & then paired student t test . Data was analysed with statistical expectorate. The procedure was performed once daily SPSS software package.The level of significance was 11 morning, after breakfast & was supervised by the set at 5%. examiner by visiting the school every day in the morning. The subjects were given with the assigned treatment III. Results group the mouthrinses in a packet and instructed to 90 subjects were included in entire study with repeat the procedure before retiring to bed at night for 30 subjects allocated in each group . On comparison of th the next 14 days. During the intervention period,no plaque scores from Baseline to 14 day there was influence on personal oral hygiene procedures was astatisticallysignificant reduction with mean differences exerted the subjects were encouraged to maintain of 1.05 and 0.87 for chlorhexidine and probiotic routine oral hygiene & also instructed to maintain strict group(p<0.05).The reduction in mean plaque score was compliance. found to be greater for chlorhexidine group than the probiotic group.But their was no statistically significant A day after the 14 days of intervention, gingival & plaque indices were recorded using same indices by reduction in placebo group for plaque scores. same examiner .This study protocol was approved by On comparison of gingival scores from baseline Volume XIV Issue IV Version I th the JSS University Research Ethics Committee. to 14 day there was a statistically significant reduction ) J DD D D

with mean differences of 0.30and 0.31 for chlorhexidine ( Clinical monitoring: clinical monitoring was performed and probiotic(p<0.05). Although the probiotic- by single examiner at baseline and 14 day. mouthrinse was significantly more effective than Monitoring of compliance and adverseevents : The chlorhexidine at 14 day (p<0.01). But their was no monitoring of compliance was assessed by instructing statistically significant difference in placebo group.

Research

Table-2 Comparision of plaque scores Medical

3.63 3.6 3.62 4 3.31 3.5 2.58 3 2.44 2.5 scores 2 1.5 Global Journal of aque 1 Baseline pl 0.5 0 14th Day

Table-3 Comparision of gingival scores

1.38 1.31 1.27 1.33 1.4 1.2 1.01 0.96 1 0.8 0.6 gival scores 0.4 Baseline in

G 0.2 on 14th day 0

2014

Year

12 IV. Discussion bacteria, all three inhibited the growth ofthe periodontopathic bacteria and S. mutansby more than This controlled comparative clinical trial 90%. This novel observation was also revealed in a demonstrated that the probioticmouthrinse and the study done by Margarita et al12, it was concluded that L. chlorhexidinemouthrinse produced significant reduc- Reuteri containing probiotic tablets are able to colonize tions in supragingival plaque and gingivitis when used the saliva and the subgingival habitat of some gingivitis as adjuncts tosubjects’ usual mechanical oral hygiene patients. The use of the probiotic was associated with a procedures. These findings add to the body of data reduction of total bacterial counts in saliva and

supporting the effectivenessof these two antiplaque/ reductions in the numbers of selected periodontal

antigingivitis products.The finding that the respective 14 pathogens. day plaque and gingivitisreduction indicates that the two It is probably the production ofsome active mouthrinseshad omparable clinical effectiveness. compounds such as bacteriocin or biosurfactant, which The data in the study compares favourably with those is the most likely reason for the antimicrobial effect of 9 from the study performed by Krasse et al , A 14-day 13,14

Volume XIV Issue IV Version I the probiotic powder . Another crucial realm of intake of L. reuteriled to the establishment of the strain in probiotic bacterial clinical impact is mechanism by J the oral cavity and significant reduction of gingivitis and

() which they act, thus improving the intestine and over all plaque in patients with moderate to severe gingivitis. health .Several reports have documented the ability

A gingival infection is caused by a mix of Gram ofprobiotic bacteria to inhibit; cell association,

positive and Gram negative species and characterized colonization and invasion by pathogenic bacteria.13, 15, 16 by pronounced leucocyte infiltration and inflammatory In a study done by khanfari17, the research aimed to Research exudation in the marginal area. The mechanism of investigate the induction or reduction of S. probiotic action in the oral cavity is not fully understood, mutansgrowth as it is a dominant bacterium producing

but is commonly explained by the combination of Local dental plaque. In conclusion, the results showed that Medical and systemic immunomodulation as well as non probiotic strains and probiotic chocolate can inhibit the

immunologic defense mechanisms. The study reported growth of oral isolates of S. mutans, but their capacity by SvanteTwetman et al10 , that have examined Short- differed significantly between the various strains. term effect of chewing gums containing probiotic In our study we used probioticmouthrinse Lactobacillus reuteri on the levels of inflammatory containing combination of lactobacillus strains and mediators in gingival crevicularfluid.The authors strain of bifidobacterium and Sacchromyces that reported significant reduction in Cytokines TNF-α and IL- contains 1.25 billion freeze dried bacterial combination.It Global Journal of 1β , which are considered central mediators of pro- is possible, in the complex environment of the human

inflammatory cascade causing damage. This result, to mouth , that probiotic “cocktails” of multiple strains some extent explained the mechanism of probiotic would be more effective than any single probiotic agent. action in the oral cavity. This combination of probiotic strain was similar to those In the light of present findings , our study results used by Haukoja et al16.The author reported the clinical also showed a significant reduction in gingival status on treatment of periodontitis and gingivitis seems to be a short – term administration of probiotic mouthrinse. The potential target for probiotic lactic acid bacteria or results are also in consistent with study doneby to bifidobacteria.A basic prerequisite to be an oral Kanget al11, studies on three strains ofL. probiotics is the ability to bond and inhabitant over the Reuteridemonstrated a centrifuged supernatant oral mucosal surfaces. Action of the probiotic strains on inhibitory effect on periodontopathic and cariogenic the oral cavity is dubious as oral mucosa is not their

© 2014 Global Journals Inc. (US) To Evaluate the Effect of Probiotic Mouthrinse on Plaque and Gingivitis among 15-16 Year Old School Children of Mysore City, India- Randomized Controlled Trial innate habitation. The study proved that lactobacilli scientific evaluation of the mechanisms of the probiotic strains maintain oro microbiological balance. But the activity even a more complicated task. there is negligible proof that these lactobacilli strains are momentary or stable oral colonizers. VII. Recommendations In the present study only the effect of short term Enlarging the duration of treatment may be an administration of probiotics was assessed. As this also alternative to assess the effects of prolonged use on resulted in significant reduction of plaque and gingival oral mucosa and teeth. In addition, since our findings status it seems plausible that prolonged administration have indicated a good safety pattern of the product in a of probiotic preparations may have a preventive role 14-day regimen, long-term trials are now encouraged to against development of plaque and gingivitis. check The subjects selected in this study were 15-16 years age group, which was important for the present References Références Referencias study, for the assessment of periodontal disease

18 1. Stamatova I. Probiotic activity of Lactobacillus 2014 indicators in adolescents .This age group is considered delbrueckii subsp. bulgaricus in the oral cavity. to markperiodontal manifestations related to Helsinky: Helsinky; 2010. Year endogenous sex hormones19. Puberty marks initiation of 2. Arezoo T, Rooha K et al. The effect of a probiotic changes from maturation into adulthood20. S everal 13 21, 22, 23 strain (Lactobacillus acidophilus) on the plaque cross-sectional and longitudinal studies have formation of oral streptococci. Bosnian Journal of demonstrated an increase in gingival inflammation Basic Medical Sciences 2011;11 (1) : 37-40 ( online) without accompanying an increase in plaque levels 3. Ramachandran S, Shree V, Dhinesh R et al. during puberty. Both estradiol and progesterone have Probiotics the promising future- A Review. : been shown toselectively accumulate by P.intermedia as SEAJCRR 2013; JAN-FEB 2(1):98-105. a substitute for vitamin K, and thus postulated to be 4. Guidelines for the Evaluation of Probiotics 24 acting as a growth factor for this microorganism. inFood.Report of a Joint FAO/WHO WorkingGroup Another reason for selecting this age group was on Drafting Guidelines for the Evaluation of the intellectual ability of the child. In accordance with Probiotics in Food. Jean Piaget at the age of seven years a child largely 5. Jindal G , Pandey R K , Agarwal J;A Comparative corresponds to an increase in cognitive development evaluation of probiotics on salivary mutans where by the child develops a sense of semi- logical streptococci counts in Indian children; European reasoning to infer physical cause- effect relation- Archieves of Pediatric Dentistry;2011:4;211-216. Volume XIV Issue IV Version I nships.Thus in this age group a positive compliance 6. Esber Caglar, Sule Kavaloglu Cildir, Semra Ergeneli; ) J DD D D

could be expected from a child. To our knowledge only

Salivary Mutans Streptococci and lactobacilli levels ( one study reported use of oral probiotic in the age after ingestion of the probiotic bacterium Lactob- 5 group between 7-14 years . acillus reuteri ATCC55730 by straws or tablets; Acta Odontolgica Scandinavica; 2006: 64; 314-318. V. Conclusion 7. Turesky S, Gilmore N D, Glickman I. Reduced Research Probiotic therapies, once discussed primarily in Plaque formation by the chloromethyl analogue of the context of “complementary” or “integrative” victamine C. J Periodontol.1970; 41:41-43. 8. Loe H, Silness J. Periodontal disease in pregnancy , medicine, are entering the therapeutic mainstream in Medical maintaining the oral health. This concept prompts a new Prevalence and severity. Actaodontologica Scandi- navica.1963;21: 533-551. Horizon on use of probiotic mouthrinse in reduction of 9. Krasse P, Carlsson, B, Dahl ., Paulsson A, Nilsson, plaque and gingivitis. A. &Sinkiewicz G. Decreasedgum bleeding and

VI. Limitations reduced gingivitis by the pro-biotic Lactobacillus reuteri. Swedish Dental Journal.2006; 30: 55– 60. It is pertinent to highlight some limitations of this 10. SvanteTwetman, Bilal D , Mette K et al. Short term Global Journal of study in order to subsidize future clinical trials in this effect of chewing gums containing probiotic field as follows. Lactobacillus reuteri on the levels of inflammatory (i)Probiotic effects are strain-specific, thus each mediators in gingival crevicular fluid. Acta Odont- individual bacterial strain needs to be tested separately, ologica Scandinavica. 2008 ; 67:19-24. and the effects described for one strain cannot be 11. Kang MS, Oh JS, Lee HC, Lim HS, Lee SW, Yang directly applied to others. Unfortunately, mislabelling of KH, et al. Inhibitory effect of Lactobacillus reuteri on strains in probiotic products seems to be a common periodontopathic and cariogenic bacteria. J problem . On the other hand, multispecies or multistrain Microbiol. 2011;49 (2):193-9. probiotic products can be even more effective than 12. Margarita I, David H, Edvardo M et al. J clin products with only one bacterial strain, making the Periodontol.2012;39:736-744.

13. Silva M, Jacubus N V, Deneke C et al. Antimicrobial 19. Ferris GM. Alteration in female sex hormones: their substance from a human Lactobacillus strain. effect on oral tissues and dental treatment. Antimicrob Agents Chemother 1987;31:1231-1233. Compendium 1993;14:1558-1570. 14. Morita M, Whang H.L. Association between oral 20. Mariotti A. Sex steroid hormones and cell dynamics malador and adult periodontitis: areview. Jclin in the periodontium. Crit Rev Oral Biol Med 1994;5: Periodontol 2001;28: 813-819. 27- 53. 15. Haukioja A, Yli- Knuuttila H, Loimaranta V et al. Oral 21. Hefti A, Engelberger T, Buttner M. Gingivitis in Basel adhesion and survival of probiotic and other school children. Helv Odontol Acta 1981;25:25-42. lactobacilli and bifidobacteriainvitro. Oral Microbioli- 22. Nakagawa S, Fujii H, Machida Y, Okuda K. A mmunol 2006; 21: 326-332. longitudinal study from prepuberty to puberty of gingivitis. Correlation between the occurrence of 16. Haukoija A et al. Probiotic Lactobacilli and Bifidob- Prevotella intermedia and sex hormones. J Clin acterium in the mouth: invitro studies on Saliva Periodontol 1994;21:658-665. mediated Functions and acid production. 2009. 2014 23. Saxen L, Nevanlinna HR. Autosomal recessive 17. Anita Khanafari, Sepideh H P, Maryam T P et al. inheritance of juvenile periodontitis: test of a Year Investigation of probiotic chocolate effect on hypothesis. Clin Genet 1984;25:332-335. streptococcus mutans inhibition. Judishapur J 14 24. Szulc P, Hofbauer LC, Heufelder AE, Roth S, Microbiol 2012;5(4): 590-597. Delmas PD. Osteoprotegerin serum levels in men: 18. World Health Organization. Geneva. Oral Health correlation with age,estrogen, and testosterone surveys Basic Methods. 2004. status. J Clin Endocrinol Metab 2001;86:3162-3165.

CONSORT FLOW DIAGRAM

Volume XIV Issue IV Version I J () Research Medical Global Journal of

© 2014 Global Journals Inc. (US) Global Journal of Medical Research: J Dentistry and Otolaryngology Volume 14 Issue 4 Version 1.0 Year 2014 Type: Double Blind Peer Reviewed International Research Journal Publisher: Global Journals Inc. (USA) Online ISSN: 2249-4618 & Print ISSN: 0975-5888

A 3- Year Evaluation of Anterior Open Bite Treatment Stability with Occlusal Adjustment By Daniel Celli, Alessandro De Carlo, Enrico Gasperoni & Roberto Deli University of the Sacred Heart, Italy

Abstract- Objective: To evaluate the effect of deciduous teeth grinding during mixed dentition, by the control of permanent molars eruption, using contemporary MEA appliance and palatal grid for anterior open-bite treatment. Materials and Methods: The sample consisted of 31 patients with a pre-treatment mean age of 9.09 years. At the time of drawing up this manuscript, 14 patients of the entire sample reach the 3 years follow-up. The occlusal adjustment procedure was performed in centric relation. Every patient was treated in the second phase with fixed arch wires and finally a fixed lower retainer was placed. Pretreatment and posttreatment cephalometric changes were compared with dependent t tests. Results: Superimposition of pre- and post-treatment cephalometric tracings, showed an advancement of A-point and ANS towards an anterior-lower direction. Overbite increased significantly with treatment and caused significant changes in other skeletal and dentoalveolar variables. Keywords: open bite, orthodontic, orthodontic appli - ances, occlusal adjustment. GJMR-J Classification: NLMC Code: WU 105

A3-YearEvaluationofAnteriorOpenBiteTreatmentStabilitywithOcclusalAdjustment

Strictly as per the compliance and regulations of:

© 2014. Daniel Celli, Alessandro De Carlo, Enrico Gasperoni & Roberto Deli. This is a research/review paper, distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License http:// creativecommons. org/licenses/by- nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

A 3- Year Evaluation of Anterior Open Bite Treatment Stability with Occlusal Adjustment

Daniel Celli α, Alessandro De Carlo σ, Enrico Gasperoni ρ & Roberto Deli Ѡ

Abstract- Objective: To evaluate the effect of deciduous teeth of incisor guidance and canine disclusion, resulting in grinding during mixed dentition, by the control of permanent molar cuspal wear, exacerbation of temporomandibular molars eruption, using contemporary MEA appliance and dysfunction, lisping and involuntary spitting when palatal grid for anterior open-bite treatment. speaking, posterior cross bite with functional shift of the Materials and Methods: The sample consisted of 31 patients mandible related to a posterior collapse of the maxilla, 2014 with a pre-treatment mean age of 9.09 years. At the time of and maxillary incisor root resorption. 1,2,3 drawing up this manuscript, 14 patients of the entire sample

Skeletal open bite is usually considered as a Year reach the 3 years follow-up. The occlusal adjustment deviation in vertical relationship of the maxillary and procedure was performed in centric relation. Every patient was 15 treated in the second phase with fixed arch wires and finally a mandibular dental arches with a lack of contact between fixed lower retainer was placed. Pretreatment and opposing segments of teeth. If however, a dento- posttreatment cephalometric changes were compared with alveolar compensatory mechanism is involved, functi - dependent t tests. onal occlusion can be reached.4 Results: Superimposition of pre- and post-treatment Therefore, orthodontic treatment consisted cephalometric tracings, showed an advancement of A-point mainly of dento-alveolar changes and modification of and ANS towards an anterior-lower direction. Overbite oral habits. In case of unfavourable skeletal patterns, it increased significantly with treatment and caused significant could be necessary an orthognatic surgery correction.5 changes in other skeletal and dentoalveolar variables. The Unfortunately, many authors reported significant dependent t test analysis confirmed the statistical significance relapse of open bites treated either surgically or with of the results showed (t test 0,000137, P< 0.05). After 3 years orthodontic appliances. Skeletal changes greater than of follow-up, the sample (n=14) show minimal changes in those observed in untreated adults have been noted cephalometric values beyond 1 year post-surgery in adult patients who had Conclusion: The selected sample showed a variable skeletal 6,7

surgical correction of a long face deformity. Volume XIV Issue IV Version I relationship except for a marked anterior open-bite which underwent this treatment procedure. Despite these odds, the Occlusal adjustment for the correction of ) J DD D D

anterior open bite is a therapeutic method already findings of this study suggest that openbite treatment with ( occlusal adjustment provides statistically significant results described and not very widespread in the literature. Few and clinically good stability over time. cases have been reported recently with an occlusal Keywords: open bite, orthodontic, orthodontic appli - vertical correction, by grinding, along orthodontic ances, occlusal adjustment. therapy. Janson, Crepaldi et al. [2008] reported change in the occlusion, function and dentin sensitivity by Research I. Introduction occlusal adjustment on permanent teeth. Spena and

alocclusions characterized by anterior open bite Medical

are often difficult to treat successfully. 1 Greenlee GM, Huang GJ, Chen SS, Chen J, Koepsell T, Hujoel P. M Numerous theories have been proposed for Stability of treatment for anterior open-bite malocclusion: a meta- aetiology of open bite, including heredity, unfavourable analysis. Am J Orthod Dentofacial Orthop. 2011 Feb;139(2):154-69 2 growth patterns, digit habits, enlarged lymphatic tissue Greenlee GM, Huang GJ, Chen SS, Chen J, Koepsell T, Hujoel P. Stability of treatment for anterior open-bite malocclusion: a meta- function, health, and stability may occur with anterior analysis. Am J Orthod Dentofacial Orthop. 2011 Feb;139(2):154-69 open bite. These difficulties may include diminished 3 Wanjau J, Sethusa MP. Etiology and pathogenesis of anterior open

bite: a review. East Afr Med J. 2010 Nov;87(11):452-5 dental aesthetics during speech and when smiling, lack Global Journal of 4 Mestrovic S.R., Lapter M., Muretic Z., Kern J., dentoalveolar

characteristics in subjects with anterior open bites Acta Stomatol Croat

2000; 169-172 5 Reyneke JP, Ferretti C. Anterior open bite correction by Le Fort I or Author α: Visiting Professor, private practice of orthodontics in bilateral sagittal split osteotomy. Oral Maxillofac Surg Clin North Am. Pescara, Italy. e-mail: [email protected] 2007 Aug;19(3):321-38, v. Review Author σ: PostGraduate student, private practice in Pescara, Italy. 6 Proffit WR, Bailey LJ, Phillips C, Turvey TA. Long-term stability of e-mail: [email protected] surgical open-bite correction by Le Fort I osteotomy. Angle Orthod. Author ρ: Private practice of orthodontics in Rimini, Italy. 2000 Apr;70(2):112-7.. 7 e-mail: [email protected] Bondemark L, Holm AK, Hansen K, Axelsson S, Mohlin B, Brattstrom Author Ѡ: Professor and Director, Postgraduate program (school of V, Paulin G, Pietila T. Long-term stability of orthodontic treatment and specialization) in Orthodontics, Catholic University of the Sacred Heart, patient satisfaction. A systematic review. Angle Orthod. 2007 Rome, Italy. e-mail: [email protected] Jan;77(1):181-91

Gracchus [2008] reported a vertical progressive 12). The mean age at the end of the treatment was reduction of the deciduous teeth with braces and 12.68 years (SD 1.58, range 11 – 15.5). All the patients functional exercises. were scheduled for a midterm follow-up at 3 years after The aim of the present study was to evaluate treatment. At the time of drawing up this manuscript, 14 the effect of deciduous teeth grinding during mixed patients of the entire sample reached the 3 years follow- dentition in the occlusion, by the control of permanent up. The occlusal adjustment procedure was performed 8 molars eruption, using contemporary maxillary in centric relation, according to the method of Okeson. expansion appliance and palatal grid to block the action All patients signed an informed consent for the of tongue muscles on dentoalveolar remodeling. orthodontics treatment and the necessary follow-up. Statistical analyses of the results and a 3 years follow-up a) Cephalometric Analysis were showed. All cephalometric radiographs were realized at pre-treatment (T1), immediately post-treatment (T2), and II. Material and Methods after three year (T3). They were digitized in double-blind

2014 A sample consisted of 31 patients (15 male, 16 by two primary authors, using TopCeph® software female), was obtained from the files achieved during analysis. The cephalograms were then verified for Year private practice in Pescara, Italy. All patients originally landmarks location and anatomic contours in order to 16 had an anterior open-bite malocclusion, with pre- eliminate any casual errors by the operators. All treatment mean age of 9.09 years (SD 1.37, range 7 - cephalometric easurements are described in Table I. Table I : Cephalometric values used to evaluate the samples

Cephalometric measurements SNA Angle between lines S-N and N-B SNB Angle between lines S-N and N-B ANB Angle between lines N-A and N-B Wits Distance between perpendicular projections of Points A and B on the functional occlusal plane FMA Frankfort mandibular plane angle: angle between lines Po-Or and Go-Me Sn.GoGn Angle between lines S-N and Go-Gn Sn.anspns Angle between lines S-N and ans-pns (maxillary plane) anspns.GoGn Go geometric Angle between posterior (Go-Ar) and lower borders (Go-Me) of the lower jaw (+1)/anspns Angle between long axis of upper incisor and ans-pns Volume XIV Issue IV Version I (-1)/GoGn Angle between long axis of lower incisor and Go-Gn

J Overjet Distance between incisal edges of maxillary and mandibular central incisors, parallel to Frankfort

() plane Overbite Distance between incisal edges of maxillary and mandibular central incisors, perpendicular to occlusal plane Interincisal angle Angle formed by long axis of the upper incisor and long axis of the lower incisor Research Any disagreements were solved by retracing the c) statistical analyses landmark or structure to the mutual satisfaction of both All data were entered into spreadsheet Office

Medical operators. Excel 2007 (Microsoft Corporation. Redmont, Washington State) and processed to calculate the b) Inclusion Criteria mean, median, standard deviation, minimum value, In 31 patients presented to clinic observation maximum value. To compare the pre-treatment, post- the initial examination revealed an 100% of anterior open treatment cephalometric changes, dependent t tests bite, a 62% of mouth breathing, 55% of muscle deficit were used. The follow up cephalometric values were and 70% of lip incompetence at rest. The sample compared only among the small sample size (n=14) for showed different skeletal relationship: 33.3% class III,

Global Journal of the post-treatment and 3 years after treatment. The level 26.7% class II and 40% class I. The patient’s long- of significance was 5%. These analyses were performed standing tongue-thrust habit had contributed to an with PhStat 2 software (statistic add-in Microsoft Excel, anterior open-bite up to - 7 mm and an over-jet up to 9 version 2.7, Prentice Hall, Inc., Pearson Education). mm. The patient maintained good oral hygiene and showed no evidence of periodontal disease.

8 McNamara JA Jr, Seligman DA, Okeson JP. Occlusion, Orthodontic treatment, and temporomandibular disorders: a review. J Orofac Pain. 1995 Winter;9(1):73-90. Review

The active arms of the appliance are extended to the III. Treatment P lan canines, embraced them, with cannulas for the insertion Treatment objectives aim to correct the anterior of a lingual grid at the end of the activation. open bite and achieve ideal overbite and overjet, correct During the period of RME treatment, the the transversal discrepancy of the two dental arches deciduos molars are ground with a diamond bur, to increasing the space for the future permanent teeth, and anticipate and control the contemporary eruption of the achieve a correct Class I dental relationship. permanent first molars, and thus, the vertical A rapid palatal expander HYRAX type is inserted dimension.(Fig.1) between the second deciduous molars and canines.

2014

Year

Figure 1 : Occlusal grinding of the deciduos teeth and Rapid maxillary expansion during treatment The expansion time was 3.4 to 4 weeks. A lingual grid was positioned just after the rapid maxillary expansion to prevent the wrong lower tongue posture and allow subsequently the setting up of an oral seal during deglutition. The rapid maxillary expansion was kept for six months of retention.

Volume XIV Issue IV Version I

IV. T reatment Progress ) J DD D D

( After the treatment was suspended, maxillary and mandibular arches were bonded with an HSDC (hybrid system Daniel Celli), an hybrid straightwire appliance: anterior conventional brackets (STEP, Leone® s.p.a, Florence, Italy) and posterior passive self Research ligating brackets (F1000, Leone® s.p.a, Florence, Italy ). If necessary strategic brackets positioning was used. A .014” or 016” nickel titanium main archwire was placed Medical for initial alignment depending on the degree of dental crowding. Over the next seven/nine months, the arch - wires were generally stepped up to .016x.025 HANT, .019” x .025” HANT (heat activated nichel titanium), .020” Australian stainless steel, .019” x .025” stainless steel wire. Intermaxillary elastics were used with the last leveling arch wire to correct the occlusion and the dental Global Journal of open bite. The case was finished with a sectional arch wire .019” x .025” stainless steel on the maxillary arch and a .016” Ni-Ti on the lower arch, with intermaxillary elastics worn to maintain the correction. (Fig. 2)

The pre-treatment overbite had a mean value of -2.5 mm (SD - 2.22, median – 2, range -7 to 0) while post-treatment overbite had a mean of 1.75 mm (SD 1.75, median 1.75, range 0 to 3). Overbite increased significantly with treatment and caused significant changes in other skeletal and dentoalveolar variables. In fact there was a mean increase in overbite after the therapeutic protocol used of 4.25 mm (SD 2.58, median 3.5, range -0.5 to 7.5) The dependent t test analysis confirmed the statistically significant of the results sho - wed (t test 0,000137, P< 0.05). There was a statistically significant increase in other dentoalveolar cephalometric values (-1/GoGn; interincisal angle); the vertical facial 2014 pattern variables, specially the maxillary plane (SN/anspns; anspns/GoGn), had statistically significant Year reductions. Starting from the dentoalveolar pattern, the 18 pre-treatment -1/GoGn changed from an average of 95.00 (SD 9.64, Median 93, range 76 to 114) to an average of 91.63 (SD 9.54, Median 94, range 70 to 104). The pre-treatment interincisal angle mean was 118.5 (SD 11.689, Median 121, range 98 to 138) while the mean value after treatment was 123.5 (SD 8.691, Median 124.5, range 116 to 145) (Table II). Upon the whole sample, 30 patients had a positive overbite after the therapeutic protocol whereas 1 had a negative overbite (3.23% of the patients) due to the lack of patient cooperation and therefore, he was excluded from the statistical analysis. The mean changes of the other variables and their standard deviations are also shown on Table III. After 3 years of follow-up, the sample Volume XIV Issue IV Version I (n=14) showed minimal changes in cephalometric

J values chosen, as confirmed by the statistical results () shown on Table IV. Of the 14 patients treated, five reported almost the same values as at the end of treatment. Research

Medical Figure 2 : Treatment progress with nickel titanium main archwires and anterior open bite closing during the treatment V. Results At the end of active treatment, the brackets were debonded, and a fixed retainer was placed on the

Global Journal of lower anterior arch, while a wraparound removable retainer, for the upper dental arch was delivered. The mean time of active treatment was 3.22 years (SD, 0.93). Post-treatment facial and intraoral photographs showed good aesthetic, skeletal balance and good functional results in all the patients. Final occlusal results, dentoalveolar compensation and root angulations were acceptable, with an adequate overjet and overbite. Superimposition of pre- and post-treatment cephal - ometric tracings, showed an advancement of A-point and ANS towards an anterior-lower direction.

Table II : Cephalometric results before and after treatment calculated by the Mean, Median and Standard Deviation (sample n=30) Before Treatment After Treatment Cephalometric Mean Median SD Mean Median SD measurements SNA 81,141 81 4,063 81,090 81 4,437 SNB 77,883 77,75 3,892 78,272 77 4,557 ANB 3,266 4 2,237 2,818 3 1,453 Wits -2,091 -2,05 3,368 -2,163 -2,5 2,806

FMA 29,85 29 5,139 31 31 5,196 Sn.GoGn 38,641 39,35 5,989 38,272 38 5,178 Sn.anspns 6,716 8,5 3,461 8,6 10 3,388 anspns.GoGn 32,083 31,5 4,010 30,6 31 4,753 Go 132,5 131 5,435 131,273 128 6,679 2014 (+1)/anspns 113,167 112,5 6,912 113,545 115 3,939 (-1)/GoGn 95,008 93 9,644 91,636 94 9,542 Year Overjet 3,291 3,5 2,879 2,863 3 1,266 19 Overbite -2,5 -2 2,225 1,75 1,75 1,138 Interincisal angle 118,5 121 11,689 123,5 124,5 8,691

Table III : Cephalometric changes before and after treatment and results of dependent t tests (P< 0.05)

Change before -after Cephalometric Mean Median SD P measurements SNA 0,05 0 0,373 0,6778 SNB 0,389 0,75 0,664 0,37941 ANB 0,448 1 0,783 0,58042 Wits 0,071 0,45 0,562 0,87619 FMA 1,15 2 0,056 0,35907 Sn.GoGn 0,368 1,35 0,81 0,40987

Sn.anspns 1,883 1,5 0,073 0,02875* Volume XIV Issue IV Version I

Anspns.GoGn 1,483 0,5 0,743 0,0483* ) J DD D D Go 1,227 3 1,244 0,63869 ( (+1)/anspns 0,378 2,5 2,972 0,81503 (-1)/GoGn 3,371 1 0,102 0,03909* Overjet 0,428 0,5 1,61 0,45294 Overbite 4,25 3,5 2,58 0,000137*

Interincisal angle 5 3,5 2,997 0,04786* Research

Table IV : Cephalometric results at the end of the treatment and after 3 years of follow-up (sample n=14) Medical After Treatment Follow-up 3 years

Cephalometric Mean Median SD Mean Median SD

measurements

SNA 77 77 1,632 77,25 77,5 1,707 SNB 74,625 74,75 2,286 74,75 75 2,217 ANB 2,375 2,5 1,108 2,5 2,5 1,29 Wits -2,95 -3,4 2,23 -2,25 -2 2,217 Global Journal of FMA 28,75 29 2,986 28,175 27,85 3,374 Sn.GoGn 40 39,5 3,162 39,05 38,5 4,18 Sn.anspns 11,525 10,8 2,025 11,25 11,5 0,957 anspns.GoGn 29,15 29,8 3,875 29,1 29,2 3,583 Go 130,5 130,5 5,8 130 130 5,77 (+1)/anspns 115,375 116,5 2,625 115,75 116,5 2,629 (-1)/GoGn 94,25 94,5 1,707 95,975 96 1,862 Overjet 2,75 3 1,258 2,75 3 1,258 Overbite 1 0,75 0,707 1,2 1,15 0,62

Interincisal angle 118 117 5,887 118 117 4,031

V I. Discussion The effectiveness of the tongue spurs has been repeatedly the subject of criticism and literature review. The treatment protocol described for the open Its effect changes, depending on various parameters bite correction, is composed of a combination of progressive vertical reduction of the deciduous first and second molars and fixed appliance that requires minimal patient’s compliance. From the analysis of the treated patients, in almost all of them the therapeutic objectives were reached. The selected sample (n=30) showed a variable skeletal relationship except for a marked

anterior open-bite that has been underwent this

treatment procedure. Although these odds, related to subsequent different cephalometric sagittal markers, 2014 they can be considered indicative of the significant

Year scientific value of the tested protocol that can be applied in any different subjects and clinical situations. 20 Rapid maxillary expansion (RME) is a universally employed technique for correction of posterior cross- bites and gain in arch perimeter in patients with tooth- size/arch-size discrepancies, like skeletal Class II and Class III. 9 The device leads mainly skeletal and alveolar volume variations of the palate, with orthopedic effect of rapid expansion, and subsequently in selected cases, antero-posterior and vertical mandibular changes in 10 skeletal Class II patients. Unfortunately a slight relapse occurs after device removal in long term, the greates being in intercanine width.11Mainly expansion stability could be due to three factors: young age of the patients, which

Volume XIV Issue IV Version I led to a good orthopedic result, prolonged retention period, which permitted complete remineralization of the J () palatine suture, and repositioning of the tongue within the arches following an increase in upper diameter.12 Rapid maxillary expansion is an important treatment factor related to the open bite correction. It is also associated with a significant increment in nasal Research volumes and in the transverse diameter of the maxilla, with statistically significant increase respectively in

Medical decongested total nasal volumes and in binasal cavity. Regard to breathing posture, the role of this procedure still remains debatable.13 The anterior tongue rest posture plays an etiologic role in the relapse of anterior open-bite. 14Th e 11 open bite reduction and its stability can also be Gurel HG, Memili B, Erkan M, Sukurica Y. Long-term effects of rapid maxillary expansion followed by fixed appliances. Angle Orthod. 2010 attributed to the tongue spurs, which interfere with the Jan;80(1):5-9 wrong lower tongue posture and with the establishment 12 Gracco A, Malaguti A, Lombardo L, Mazzoli A, Raffaeli R. Palatal Global Journal of of an oral seal during deglutition.15 volume following rapid maxillary expansion in mixed dentition. Angle Orthod. 2010 Jan;80(1):153-9 13 Ceroni Compadretti G, Tasca I, Alessandri-Bonetti G, Peri S, D'Addario A. Acoustic rhinometric measurements in children undergoing rapid maxillary expansion. Int J Pediatr Otorhinolaryngol. 2006 Jan;70(1):27-34 9 Lima Filho RM, de Oliveira Ruellas AC. Long-term maxillary changes 14 Condò R, Costacurta M, Perugia C, Docimo R. Atypical deglutition: in patients with skeletal Class II malocclusion treated with slow and diagnosis and interceptive treatment. A clinical study. Eur J Paediatr rapid palatal expansion. Am J Orthod Dentofacial Orthop. 2008 Dent. 2012 Sep;13(3):209-14 Sep;134(3):383-8 15 Urzal V, Braga AC, Ferreira AP. Oral habits as risk factors for anterior 10 Lima Filho RM, de Oliveira Ruellas AC. Mandibular behavior with open bite in the deciduous and mixed dentition - cross-sectional slow and rapid maxillary expansion in skeletal Class II patients: a long- study. Eur J Paediatr Dent. 2013 Dec;14(4):299-302 term study. Angle Orthod. 2007 Jul;77(4):625-31

© 2014 Global Journals Inc. (US) A 3- Year Evaluation of Anterior Open Bite Treatment Stability with Occlusal Adjustment such as length of spurs use, age of stakeholders, the results, especially for five patients showing almost any skeletal class and function, design spurs. The tongue change at the follow-up (Fig 3). It was interesting and spurs force a change on the anterior tongue rest relevant that larger over jets and tooth display (at rest) posture, which in turn allows incisors to erupt, closing disappeared and got a natural harmony to patient’s 16 the anterior open bite. face. The authors decided to perform occlusal adjustment only on deciduous molars. Grinding is an aggressive procedure for the dental tissues, with permanent effects on teeth. Working on deciduous teeth becomes a transitional and non-invasive procedure for the patient. The results confirmed previous studies demonstrating the efficacy of the procedure to close an 17,18 open-bite. Selective grinding, to be effective, must

be achieved during the period of growth and, namely, at 2014 the moment of maxillary and mandibular permanent teeth eruption. A loss of occlusal contact between the Year upper and lower molars resulted at this time. The 21 deciduous teeth will be ground up to that a physical contact would be re-establish with the antagonist molars. The proper management of an open-bite patient is based on the choice of a therapeutic protocol that takes into account the difficulties and long-term stability of this treatment. Early treatment of open bite allows compensatory craniofacial growth and reduces the need for a second phase of treatment that might involve extractions or orthognathic surgery. When the open bite correction begins in deciduous or mixed dentition, as in the treatment protocol proposed, the appliances could be very effective and produce faster response in 19 younger subjects. Finally, the use of multiple therap- Volume XIV Issue IV Version I eutic options allows us to get satisfactory and stable ) J DD D D

results over time, as demonstrated by the 3-years follow ( up. Accordingly, it is important to notice the cephalometric changes after the therapeutic protocol. There was a statistically significant decrease of the facial Research pattern angles as well as the dento-alveolar terms. Ans- Pns plane rotate clockwise in the mid-sagittal plane. The

upper and lower incisors change their position in order Medical to close the bite; therefore a good aesthetic condition and the protection of incisors guidance during protr- usion are kept over time. Although after 3 years the study presents a small sample, it’s already possible to identify a stable

Global Journal of 16 Meyer-Marcotty P, Kochel J, Stellzig-Eisenhauer A. The impact of spur therapy in dentoalveolar open bite. Aust Orthod J. 2013 Nov;29(2):145-52 17 Janson G, Crepaldi MV, de Freitas KM, de Freitas MR, Janson W. Evaluation of anterior open-bite treatment with occlusal adjustment. Am J Orthod Dentofacial Orthop. 2008 Jul;134(1):10-2 18 Spena R, Gracco A. Vertical control in nonextraction treatment of growing patients with anterior skeletal open bite. J Clin Orthod. 2008 Aug;42(8):443-9 19 Cozza P, Mucedero M, Baccetti T, Franchi L. Early orthodontic treatment of skeletal open-bite malocclusion: a systematic review. Angle Orthod. 2005 Sep;75(5):707-13. Review

Figure 3 : Intra oral photographs before treatment, at the end of treatment and after 3 years

VII. Conclusion

Volume XIV Issue IV Version I This study suggests that selective grinding of

J deciduous teeth permits to obtain fast therapeutic () results with harmless and transitory effects for dental tissue. Its action, coupled with the rapid expansion of the palate and tongue spurs, allows the closure of open bite, followed by orthodontics. The early treatment Research proposed of open-bite tendency results in a rapid control of the vertical dimension, in a significant and stable improvement of a correct and functional Medical occlusion and in perceived facial aesthetic. Global Journal of

Nonsurgical Management of Cutaneous Sinus Tract of Odontogenic Origin: A Case Report By Dr. Gautam P. Badole, Dr. Rajesh Kubde, Dr. Mohit Gunwal & Dr. Shital G. Badole VSPMs Dental college and research center, India Abstract- Draining cutaneous sinus tracts in the area of face may be caused by chronic dental infections. Misdiagnosis of these cutaneous sinus tracts usually leads to destructive invasive treatment of the skin lesions that is not curative. Diagnosis of the cause may be challenging but is the key to successful therapy. Successful repair depends primarily on removal of etiological factors. This scientific paper aims to present a case, treated successfully & closure of the tract achieved by conventional root canal therapy. Keywords: cutaneous sinus, odontogenic infection, sinus tract, trauma. GJMR-J Classification: NLMC Code: WO 460

NonsurgicalManagementofCutaneousSinusTractofOdontogenicOriginACaseReport

Strictly as per the compliance and regulations of:

© 2014. Dr. Gautam P. Badole, Dr. Rajesh Kubde, Dr. Mohit Gunwal & Dr. Shital G. Badole. This is a research/review paper, distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License http:// creativecommons. org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Nonsurgical Management of Cutaneous Sinus Tract of Odontogenic Origin: A Case Report

Dr. Gautam P. Badole α, Dr. Rajesh Kubde σ, Dr. Mohit Gunwal ρ & Dr. Shital G. Badole Ѡ

Abstract- Draining cutaneous sinus tracts in the area of face apparent healing. Root canal therapy in minimal scarring may be caused by chronic dental infections. Misdiagnosis of of skin.11 The purpose of this report is to present a case these cutaneous sinus tracts usually leads to destructive of cutaneous sinus tract successfully managed with only invasive treatment of the skin lesions that is not curative. conventional root canal treatment Diagnosis of the cause may be challenging but is the key to

2014 successful therapy. Successful repair depends primarily on II. Case Report removal of etiological factors. This scientific paper aims to present a case, treated successfully & closure of the tract A 17 year-old female patient was referred to the Year achieved by conventional root canal therapy. Department of conservative dentistry and endodontics 23 Keywords: cutaneous sinus, odontogenic infection, with a complaint of extra oral nodulous growth on her sinus tract, trauma. chin for the past five months. Patient had given a history of treatment for the same nodule from dermatologist I. ntroduction I since its appearance but not subsided. On extraoral chronic inflammation of pulpal origin is one of the examination, 0.5×0.5 cm nodule like lesion (Figure 1) reasons for an extra oral sinus of odontogenic was present on her chin. Palpation elicited nontender Aorigin. 1 The discharge of purulent exudates usually nodule and fixation of the lesion to underlying bone. is associated with periapical radiolucent area and goes Intraoral examination revealed no mucosal lesions or through tissues and structures along the path of least buccal sulcus swelling but elicited tenderness at the root resistance.2 Cutaneous lesion may develop over a long apex of 31. Pulp vitality showed negative response with period of time and is often distant from the site of 31. Periapical radiograph of mandibular left central primary infection. Hence successful management of incisor revealed periapical radiolucency (Figure 2). While these odontogenic cutaneous sinus tracts of pulpal recording the dental history patient revealed that she pathology depend on proper diagnosis.3,4 The site of met with trauma two years ago, but there was no pain Volume XIV Issue IV Version I )

present with any of the tooth. On clinical and J DD D drainage depends on the tooth which is diseased, and D the apex position relatively to muscular attachments, radiographic examination, chronic apical periodontitis ( bacterial virulence and lower host resistance.5 If the with 31 leading to extraoral sinus tract was made. Root apices of the teeth are above the maxillary muscle canal treatment was planned with 31. attachments and below the mandibular muscle 6 attachments the spread of infection may be extraoral. Research These sinus tracts occurring more frequently from infected mandibular teeth than from infected maxillary teeth and particularly on the chin or in the Medical submandibular area.7 The involved tooth is asympt- omatic as there is absence of swelling or pain results from pressure build up.7 Patient first visits a physician for evaluation and treatment. Diagnosis of cutaneous sinus tracts of dental origin presents constant challenge to practitioners.8, 9 Based on literature reports, misdiagnosis has often worsened the chronicity of the lesion Global Journal of and has pronounced effects on facial aesthetics due to unnecessary treat ments such as multiple biopsies, Figure 1 : Extra-oral sinus on chin antibiotic regimens resulting in further skin scarring.10 It has been observed that systemic antibiotic therapy will result in a temporary reduction of the drainage and

Author α σ ρ Ѡ: Department of Conservative Dentistry & Endodontics VSPM’s Dental College & Research Center, Nagpur (INDIA). e-mails: [email protected], [email protected]

Figure 2 : Periapical radiolucency with 31 Figure 3 : Post-obturation radiograph Under the rubber dam isolation, access opening was done with 31 and samples were collected for both aerobic and anaerobic culture so that effective antibiotic treatment was started. Working length was determined with apex locator (Root ZX; Morita, Tokyo, Japan.) and confirmed with intra-oral periapical radiograph. Cleaning and shaping was completed with

Volume XIV Issue IV Version I step-back technique using hand K-files (Dentsply Maillefer, Ballaigues, Switzerland). Chlorhexidine (Endo- J CHX, Prime Dental Product, Mumbai, India.) was used () as intracanal irrigant and not sodium hypochlorite, duo the risk of apical extrusion of the irrigant. Canal was dried with paper points and calcium hydroxide (RC Cal; Figure 4 : Complete healing of extra-oral sinus Prime Dental Products, Thane, India.) was placed within

Research the canal as intracanal medicament. After a week obturation was completed using gutta-percha points with cold lateral condensation technique (Figure 3). Medical Patient was evaluated for a period of 3 months showed complete healing of extraoral sinus (Figure 4). Intra oral periapical radiograph showed complete healing of periapical radiolucency (Figure 5). Global Journal of

Figure 5 : Healing of periapical lesion on radiograph

III. Discussion

The cutaneous sinus tract of dental origin is an uncommon but well documented condition in the

6 medical, dental, and dermatological literature. odontogenic cutaneous sinus tracts of endodontic Cutaneous dental sinus or Odontogenic cutaneous origin: three cases studies. Int Endod J 2009;42: sinus tract or Cutaneous facial sinus tract of dental 271–76. origin was first stated by Winstock in 1950.12 3. Spear KL, Sheridan PJ, Perry HO. Sinus tracts to the Approximately 80% of these sinuses related to chin and jaw of dental origin. J Am Acad Dermatol mandibular teeth and 20% with maxillary teeth.8 The 1983;8:486-92. characteristic lesion is erythematous, smooth, 4. Wood NK, Goaz PW, eds. Differential diagnosis of symmetrical nodule, 1-20 mm in diameter. There is oral lesions. 4th ed. St. Louis: Mosby-Year periodic drainage and crusting in some cases and the Book;1991:264. lesion is depressed below the normal skin surface. A 5. Johnson BR, Remeikis NA & Van Cura JE. cord - like tract can be felt attached to the underlying Diagnosis and treatment of cutaneous facial sinus bone.8 If the sinus tract is patient a lacrimal probe or tracts of dental origin. J Am Dent Assoc 1999;130: gutta-percha cone can be introduce into the opening 832–6. and confirmed the affected tooth on intraoral periapical 6. Laskin DM. Anatomic considerations in diagnosis 2014 radiograph. Pulp vitality test should perform on and treatment of odontogenic infections. J Am Dent suspected as well as on adjacent teeth. Culture and Assoc 1964;69:308 -16. Year sensitivity testing of discharged fluid should be 7. McWalter GM, Alexander J B, delRio CE and Knott 25 performed to rule out fungal and syphilitic infection.13 JW. Cutaneous sinus tracts of dental etiology. Oral The clinical differential diagnosis of cutaneous Surg Oral Med Oral Pathol.1988; 66:608-14. draining sinus tracts includes osteomyelitis, congenital 8. Mittal N & Gupta P.. Management of extra oral sinus fistula, salivary gland fistula and infected cyst and deep cases: a clinical dilemma. J Endod 200430: 541–7. mycotic infection. In addition, skin lesions such as 9. Tidwell E, Jenkins JD & Ellis CD et al. Cutaneous pustules, furuncles, foreign-body lesions, squamous cell odontogenic sinus tract to the chin: a case report. carcinoma and granulomatous disorders show the Int Endod J 1997; 30: 352–5. similar superficial appearance.4 10. Cantatore JL, Klein PA, Lieblich LM. Cutaneous Nonsurgical endodontic therapy is the treatment dental sinus tract, a common misdiagnosis: a case of choice if the tooth is restorable or extraction if report and review of the literature. Cutis; Cutaneous nonrestorable.11 There are different opinions regarding Medicine for the Practitioner 2002; 70: 264-265. the removal of sinus tract, some authors recommended 11. Sheehan DJ, Potter BJ & Davis LS. Cutaneous excision of cutaneous lesion and sinus in continuity at draining sinus tract of odontogenic origin: Unusual the time of treatment of the dental pathology with Presentation of a Challenging Diagnosis. South Med Volume XIV Issue IV Version I 12, 14 ) J DD D immediate plastic repair of cutaneous site. Other J 2005;98: 250–2. D believes that on removal of primary odontogenic cause 12. Winstock D. Four cases of external facial sinuses of ( cutaneous lesion heals without any intervention within 5 dental origin. Proc R Soc Med 1959; 52:749-51. to 14 days,3 dimpling and hyperpigmentation of area 13. Sakimoto E, Stratigos GT. Bilateral cutaneous sinus occurs which fade over time and a surgical revision of tracts of dental pathology : report of a case. J Oral bigger scar might be needed to provide better cosmetic Surg 1973;31:70-4. Research result in future.3, 15 14. Kwapis BW, Baker WD. Cutaneous fistula of dental origin. J Oral Surg 1956;14:319.

IV. Conclusion 15. Cloffi GA, Terezhalmy GT, Parlette HL. Cutaneous Medical

The key to a successful treatment of cutaneous draining sinus tract: odontogenic etiology. J Am sinus of dental origine must lay in healthy Acad Dermatol 1986;14:94-100. communication between the dentist and the physician in order to provide for timely recognition and treatment of such cases. Basic principles of root canal treatment should be used judiciously to create a favourable

Global Journal of environment while effectively eliminating the pathogens and giving the body's immune, healing and repair mechanism a chance to achieve the desired result.

References Références Referencias

1. Bender IB, Seltzer S. The oral fistula: Its diagnosis

and treatment. Oral Surg Oral Med Oral Pathol. 1961; 14: 1367-76. 2. Pasternak-Júnior B, Teixeira CS, Silva-Sousa YTC & Sousa-Neto MD.. Diagnosis and treatment of

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Correlation between Estrogen Deficiency and Chronic Desquamative Gingivitis in Female Patients By Pramod John Mangalore University, India

Abstract- The oral mucosa may be affected by a variety of systemic diseases and oral lesions most often may precede several mucocutaneous or systemic disorders. The systemic basis for many of the oral lesions is not clearly known. One such oral disease which may have a strong systemic basis for its pathogenesis is chronic desquamative gingivitis (CDG). In the literature there are conflicting reports as to the mechanism of pathogenesis of this clinical entity. Some investigators consider this as a unique clinical disease, whereas, others consider it as the gingival manifestation of disease processes having a strong correlation with the fluctuation of female sex hormones. This study was conducted to find out a correlation between circulating levels of serum estrogen (the female sex hormone) and occurrence of CDG in female patients.

Keywords: chronic desquamative gingivitis, estrogen, hormone replacement therapy, gingivitis.

GJMR-J Classification: NLMC Code: WU 300

CorrelationbetweenEstrogenDeficiencyandChronicDesquamativeGingivitisinFemalePatients

Strictly as per the compliance and regulations of:

© 2014. Pramod John. This is a research/review paper, distributed under the terms of the Creative Commons Attribution- Noncommercial 3.0 Unported License http:// creativecommons. org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Correlation between Estrogen Deficiency and Chronic Desquamative Gingivitis in Female Patients

Pramod John

Abstract- The oral mucosa may be affected by a variety of mediated mucocutaneous disorder which is aggravated systemic diseases and oral lesions most often may precede by local plaque accumulation and chronic irritation, or a several mucocutaneous or systemic disorders. The systemic manifestation of a number of disorders ranging from 2014 basis for many of the oral lesions is not clearly known. One vesiculobullous diseases such as cicatricial and bullous such oral disease which may have a strong systemic basis for Year pemphigoid, pemphigus vulgaris, erosive lichen planus, its pathogenesis is chronic desquamative gingivitis (CDG). In the literature there are conflicting reports as to the mechanism erythema multiforme, psoriasis and allergy, to adverse 27 of pathogenesis of this clinical entity. Some investigators reaction to a variety of chemicals and allergens or consider this as a unique clinical disease, whereas, others manifestation of metabolic and hormonal disturbances. consider it as the gingival manifestation of disease processes Though the investigators are confused about the having a strong correlation with the fluctuation of female sex etiology of CDG, many are of the opinion that there is a hormones. This study was conducted to find out a correlation strong hormonal basis for the etiology of this condition. between circulating levels of serum estrogen (the female sex It has been found that estrogen ointments when hormone) and occurrence of CDG in female patients. 7 Keywords: chronic desquamative gingivitis, estrogen, applied topically is effective in controlling this disease. hormone replacement therapy, gingivitis. Yet another therapeutic measure recommended in certain refractory cases of desquamative gingivitis is I. Introduction hormone replacement therapy (HRT) with low dose estrogen. However, this should be done under the s a disease entity, chronic desquamative gingivitis careful supervision of a physician or gynaecologist. A was first described by Tomes and Tomes in 1894. number of studies have shown that hormone replace- However, the term ‘desquamative gingivitis’ was ment therapy (HRT) with estrogen can relieve the oral Volume XIV Issue IV Version I A ) first introduced by Prinz in 1932 for the presence of J DD D discomfort in post-menopausal women, thus estab- D erythema, desquamation, erosion and blistering of ( 1 3 lishing the role of female sex hormones in the healthy attached and marginal gingiva. Glickman and Smulow maintenance of the oral tissues.6,7 stated that it is a clinical manifestation of several disorders. This is further confirmed recently by many Estrogen is produced primarily in the ovaries. Some quantity of estrogen is also produced by the

other investigators. CDG is a clinically relevant entity as Research it can affect the oral health and is mainly mediated by adrenal glands. Estrogen belongs to the category of sex certain hormonal deficiency states. Its clinical appea- steroid hormones and is a derivative of cholesterol and consists of a combination of three rings of six carbon rance is not significantly altered by traditional oral Medical hygiene measures or conventional periodontal therapy. atoms each (phenanthrene) and one ring of five carbon atoms (cyclopentane) to form a complex hydrogenated It is a fairly common complaint typically seen in females who are middle-aged or older4, 5. Many cases have also cyclopentanoperhydrophenanthrene ring system. Sig- been reported in younger women, often associated with nals for estrogen production originate in the pituitary fluctuations in the circulating sex hormone levels. gland and the levels vary throughout life depending on CDG is a clinical condition with unclear and the stage of a woman’s menstrual cycle. The three major naturally occurring estrogens in women are est - uncertain etiology. It is not a specific diagnosis but a Global Journal of rone (E1), estradiol (E2 or 17 β- estradiol or estradiol), descriptive term for non-specific gingival manifestation associated with different diseases.6 It is not a disease and estriol (E3). Estradiol is the predominant estrogen but represents a reaction pattern of the gingiva which during reproductive years both in terms of absolute conceals other pathological processes. Some investi- serum levels as well as in terms of estrogenic activity. gators consider it as a specific disease, whereas, others During menopause, estrone is the predominant circul - consider it as a manifestation of immunologically ating estrogen and during pregnancy estriol is the predominant circulating estrogen in terms of serum levels. Though estriol is the most plentiful of the three Author: Department of Oral Medicine and Radiology Kannur Dental estrogens it is also the weakest, whereas estradiol is the College and Hospital, Kerala, India. e-mail: [email protected] strongest.

variety of systemic diseases. He also proposed an II. Review of Literature 8, 9 etiologic classification for desquamative gingivitis based Richman, Abarbanel , as early as 1943 on the causative factors associated with chronic realized the significance of the female sex hormone, desqamative gingivitis such as dermatoses, hormonal estrogen, in the maintenance of gingival health and had deficiencies, abnormal response to irritation, chronic used exogenous estrogen preparations to successfully infection, and idiopathic causes. treat desquamative lesions of the gingiva. They According to Glickman and Smulow in 1964, perceived that estrogens increased epithelial kera - desquamative gingivitis is a disease which is primarily a tinization and stimulated proliferation of the epithelial degenerative process mainly affecting the gingiva. Löe cells. 14 10 in 1965 reported that gingival inflammation and Daniel, E, Ziskin and Zegarelli, EV in 1945 hyperplasia may be associated with hormonal changes analyzed twelve patients, belonging to the age group of taking place during puberty, menstruation and 21 to 67 years. According to them, the disease is 15 pregnancy. Kullander and Sonesson in 1965 had hypothetically designated as a local manifestation of a 2014 reported that many oral changes can occur as a result metabolic disturbance. Various causes of this disturbed of a decline in the estrogen levels in women. They had Year metabolism were also considered such as abnormal reported many oral changes associated with functioning of the thyroid gland and the interrelationship 28 menopause. Their investigations led to the conclusion of the vitamins and estrogens. Their data suggested that that strong relationship exists between circulating a local depletion of estrogen in the oral tissues may play hormonal levels and inflammatory changes of the oral a major causative role. Estrogen ointments applied mucosa. topically were found to be effective in controlling the 16 Jenson et al. in 1968 and Gorksi et al. in 17 disease. 1968 observed that the sex steroid hormones bind to 11 Milton B. Engel et al. in 1950 had studied the intracellular proteins with specificity and high affinity and pathogenesis of desquamative gingivitis and stated that this concept has led to the theory that steroid hormones the boundary between the epithelium and the act via the receptors to initiate biological responses. connective tissue of the gingiva is formed by an optically 18 According to Kalkwarf in 1978 and Pankhurst et al. in homogeneous ground substance, which, together with 198119, based on their extensive studies, have the embedded fibres is termed the basement mem - concluded that gingival inflammation may be commonly brane. The major component of the homogeneous seen in women taking oral contraceptive medication. ground substance is an insoluble carbohydrate-protein The nature of this inflammatory response of the gingiva

Volume XIV Issue IV Version I complex which is thought to be highly polymerized. is similar to chronic desquamative gingivitis. Therefore, Although relatively resistant to chemical treatment, it they are of the opinion that chronic desquamative J may exhibit lability in certain physiologic and pathologic () gingivitis may be caused by oral contraceptive processes. The investigators are of the opinion that medication. many of the disturbances of the gingiva originate in the Menopause and its effects on the oral health connective tissue. In desquamative gingivitis, the slig - has been extensively studied by Parvinen in 198420. He htest pressure of the finger or from an air blast causes a is of the opinion that many oral diseases, including Research clean separation of the epithelial layer from the und - chronic desquamative gingivitis could be attributed to erlying connective tissue in an almost spontaneous estrogen deficiency as in the case of post-menopausal manner. The gingiva is marked by many ulcerated and Medical state. bleeding areas. There was degeneration of the epit - Green in198621 and Greene, et al. in 198622

helium and edema and inflammation of the connective have identified estrogen receptors (ER) in the gingiva. tissue. Histopathology revealed absence of basement Later by some other investigators the mechanism of membrane. There was increased quantity of water- action of estrogen-estrogen receptor was studied which soluble carbohydrate-containing substances formed led to the identification estrogen subtypes. The classical due to the action of depolymerizing enzymes. A low estrogen receptor (ER) was renamed ER after the α level of estrogen might lie behind the symptoms in identification of ER β. Global Journal of desquamative gingivitis as the enzymatic activity of the Morishita et al. in 198823 suggested that

connective tissue is subject to hormonal influences. unbalanced secretion of sex hormones, i.e. an increase Theresa Kindler in 1954 12 first described the of estradiol and a decrease of progesterone, might be Kindler syndrome which is characterized by blistering of one of the factors promoting gingivitis during puberty. the skin, photosensitivity, and desquamation of the However, the mechanisms of the effects of these gingiva. It is a rare autosomal recessive genod - hormones in the initiation of gingival inflammation are ermatosis. Mc Carthy F. P, et al. in 1960 13 studied 40 not clearly known. Masaharu Miyagi, et al. in 199224 cases of desquamative gingivitis over a period of 12 reported a significant positive correlation between the years and concluded that chronic desquamative concentration of progesterone in the plasma of females gingivitis is actually a nonspecific manifestation of and the chemotactic ability of polymorphonuclear leuko-

© 2014 Global Journals Inc. (US) Correlation between Estrogen Deficiency and Chronic Desquamative Gingivitis in Female Patients cytes (PMN) in vitro. In males, there was no significant 2. Patients with normal growth pattern and secondary relationship between plasma levels of sex hormones sexual characteristics. and PMN chemotactic ability. Further sex hormones had 3. Patients should be free from any other endocrine no effect on the chemotaxis of monocytes. These results disorders. suggest that the altered PMN chemotaxis associated 4. Patients should have had normal menstrual history with gingival inflammation may be due to the effects of (in case of post-menopausal women) and the female sex hormones. They have also stated that the patients should have regular menstrual cycle (in gingival inflammation is exaggerated during puberty and patients who have not attained menopause). pregnancy. Altered levels of circulating sex hormones 5. At least one year should have elapsed after the last during puberty are considered to aggravate gingivitis delivery. induced by bacterial plaque. It is generally accepted 6. One week should have elapsed after the last that the bacterial plaque induces gingival inflammation menstrual cycle. through interactions with host defense mechanisms. In

b) Exclusion Criteria 2014 such defense mechanisms, phagocytic cells such as

PMN leukocytes and macrophages are suggested to The following were the exclusion criteria. play an important role. Therefore, they hypothesized that 1. Patients with severe gingival inflammation attribu- Year sex hormones may cause inflammation by their actions table to local irritants such as plaque and calculus 29 on the functions of PMNs or monocytes. or ill-fitting prosthetic appliances. Ciocca and Roig in 199525 reported the expre- 2. Acute inflammatory conditions of the gingiva such ssion of RNA-m at the specific estrogen receptors by as acute herpetic gingivostomatitis and acute means of polymerase chain reaction (PCR) studies, necrotizing ulcerative gingivostomatitis (ANUG) through which it can be assessed whether the receptor 3. Patients who underwent surgical procedures of the is functional, that is whether there is genetic control or endocrine glands or ovaries cell function control. Bonnie J. Deroo and Kenneth S. 4. Patients on hormone replacement therapy (HRT) for Korach in 200626 have reviewed estrogen receptors and any disease human disease. They have mentioned that estrogen 5. Patients with irregular menstrual history influences many physiological processes in human, not 6. Patients who are pregnant or had any recent history limited to reproduction. Estrogen is also implicated in of miscarriage the development or progression of numerous diseases. 7. Patients on hormonal contraceptives Estrogen mediates its effect through the estrogen 8. Patients with systemic contributing factors for receptor (ER), and plays a role in the development or gingival inflammation Volume XIV Issue IV Version I ) 9. Patients who are mouth breathers J severity of disease. According to them estrogens induce DD D D cellular changes through several different mechanisms. 10. Patients who are smokers ( In the classical mechanism of estrogen action, 11. Patients undergoing orthodontic treatment estrogens diffuse into the cell and binds to a protein, the 12. Patients who are diabetic estrogen receptor which is located in the nucleus. 13. Uncooperative patients who were not willing to take

part in the study Research III. Materials and Methods A Proforma was prepared to record the details The study was conducted in the Department of of the subjects included in the study. The subjects were Oral Medicine and Radiology, Amrita School of Dent- in the age group between 25 and 60 years. Medical istry, Cochin among female patients presenting with Prior to carrying out the study, the objectives of clinical signs and symptoms of chronic desquamative the study were explained to all the subjects in a gingivitis and normal subjects (the control group). language the subjects could understand and patient’s Before carrying out the study, the institutional explicit consent was obtained in the Consent Form. Ethical Committee approval was obtained. Among the This was followed by a thorough history taking 100 subjects selected for the study, 50 patients with and intra oral clinical examination as outlined in the clinical presentation of chronic desquamative gingivitis Proforma. In this study, the standard used for the clinical Global Journal of were taken as the study subjects (Group A or the study appearance of desquamative gingivitis included gingival group) and the remaining 50 patients without CDG were erythema not resulting from plaque, gingival desqua- taken as control subjects (Group B or the control mation, other intraoral and sometimes extraoral lesions, group). and complaints such as burning mouth after eating spicy foods23, 24. The clinical criteria also included the a) Inclusion Criteria presentation of fiery, red, friable gingiva which is painful The following inclusion criteria were applied and desquamates easily and the involvement of buccal while selecting the subjects of Group A: aspect of attached gingiva which were not significantly 1. Patients with clinically diagnosable chronic desqua- improved by oral hygiene measures alone. 21 Based on mative gingivitis. these clinical parameters, the free and attached gingiva

of all the patients were examined under good which match the color bands on the reagent bottle illumination and after drying the surface. The serum labels. The sample is loaded. When the system runs, the estrogen level was estimated in all the 100 patients. sample and the reagents are loaded into the reaction After adopting proper aseptic precautions, 4.0 vessel and measures chemiluminescent emission to ml blood was drawn from each of the subjects from the determine the quantity of estradiol in the sample. The median cubital vein and immediately the sample was system then automatically calculates and reports the sent for the estimation of serum E2 level. Human serum result. The estradiol test result is expressed as pg/mL. (including serum collected in serum separator tubes) or The average serum E2 level in normal menstruating plasma collected in lithium heparin (including plasma females can vary from 21 to 443 pg/mL and less than 20 separator tubes) or potassium EDTA collected in glass to 28 pg/mL, in post-menopausal women 10. or plastic may be used in the Architect Estradiol Assay. IV. Results and Observations In the clinical laboratory, the sample thus obtained is inspected for any air bubbles. If any air bubbles are Group A consisted of 50 female patients belon-

2014 present, they are removed with a disposable applicator ging to the study group having clinically diagnosed stick. The serum specimen is centrifuged after complete chronic desquamative gingivitis and Group B consisted Year clot formation; otherwise, presence of fibrin, red blood of 50 female subjects who were normal. Group A and 30 cells or other particulate matters in the serum may Group B subjects belonged to the age group of 25 to 60 cause erroneous results. The specimen may be stored years of age. The mean age of the Group A patients was for up to 7 days at 2-8˚C before being estimated for 44.52 ± 10.52. The mean age of the Group B subjects serum E2 level. The sample from the middle of the tube was 36.32 ± 8.32. The lowest age of the Group A is taken for estimation mainly to avoid any particulate patients was 25. The lowest age of the Group B subjects matter on the top or bottom of the specimen. was 25. The highest age of the Group A patients was The Architect Estradiol Assay is a delayed one- 60. The highest age of the Group B subjects was 60 step immunoassay to determine the presence of (Table 1). estradiol in human serum and plasma using Chem- iluminescent Microparticle Immuno Assay (CMIA) techn- Table 1 : Age of the patients across Group A and Group ology with flexible assay protocols, referred to as B samples Chemiflex. Architect i system manufactured by Abbot AGE (in years) Ireland, Diagnostic Division was the laboratory equip- Group A Group B ment used for the assay. Mean Mean Volume XIV Issue IV Version I In the first step, sample, specimen diluent, Lowest Highest Lowest Highest ± SD ± SD assay diluent, and anti-estradiol (rabbit, monoclonal) J 44.52 36.32 () coated paramagnetic microparticles are combined. ± 25 60 ± 25 60 Estradiol present in the sample binds to the anti- 10.52 8.32 estradiol coated microparticles. After first incubation, The mean serum estradiol (E2) level of the estradiol acridinium labeled conjugate is added to the Group A patients was 18.92 ± 18.05. The mean serum

Research reaction mixture. After a second incubation, and estradiol (E2) level of the Group B subjects was 66.44 ± washing, Pre-Trigger and Trigger solutions are then added and the resulting chemiluminescent reaction is 67.48. The lowest serum estradiol (E2) level in the Group A patients was 10. The lowest serum estradiol (E2) level Medical measured as relative light units (RLUs). An inverse relationship exists between the amount of estradiol in in the Group B patients was 10. The highest serum the sample and the RLUs detected by the Architect estradiol (E2) level in the group A patients was 92. The optical system. The installed Estradiol assay file on the highest serum estradiol (E2) level in the Group B subjects was 284 (Table 2). Architect i system helps to get assay parameter. The Architect i system is loaded with the reagent kit. The reagent carousel has color coded rings

Global Journal of Table 2 : Serum E2 level across Group A and Group B samples SERUM E2 (in pg/ml) Group A Group B Mean ± SD Lowest Highest Mean ± SD Lowest Highest 18.92 ± 10 92 66.44 ± 67.48 10 284 18.05

In univariate analysis (Table 3), among the showing age more than 40. The distribution of age is subject group (Group A), 60 % were showing age more significantly different in subject and control groups. than 40 and in control group (Group B), 32 % were

Table 3 : Comparison of variables across Group A and Group B (univariate analysis)

Group A Group B Odd’s p – Variables Number % Number % ratio Value

≤ 40 20 40.0 34 68.0 Age 3.18 0.005 > 40 30 60.0 16 32.0

≤ 20 40 80.0 10 20.0 Serum 16.0 <0.001 >20 10 20.0 40 80.0

No 32 64.0 47 94.0 Menopause 8.84 0.001 Yes 18 36.0 3 6.0

Table 4: Comparison of variables across Group A and Group B (multivariate analysis)

Group A Group B Odd’s p – Variables Number % Number % ratio Value 2014 ≤ 40 20 40.0 34 68.0 Age 1.36 0.618

> 40 30 60.0 16 32.0 Year

≤ 20 40 80.0 10 20.0 Serum 13.8 0.000 >20 10 20.0 40 80.0 31

No 32 64.0 47 94.0 Menopause 2.23 0.326 Yes 18 36.0 3 6.0

There is a high percentage of low serum E2 51% were associated with mucoc-utaneous diseases level in Group A (80%) compared to Group B (20%) and the rest with idiopathic or hormonal etiology. showing significant association (p < 0.001). Odd’s ratio However, Crispian Scully and Stephen R. Porter in is 16.0. Compared to Group B there is 16 times more 1997,2 said that desquamative gingivitis is usually chance of low level of serum E2 in Group A. related to mucocutaneous disorders such as mucous

In Group A, 36 % had attained menopause. In membrane pemphigoid and lichen planus, chemical control group, 6 % had attained menopause. Compared damage and allergic response due to mouth washes, to Group B, there is 8.8 times more chance of chewing gum, or dental materials and drugs. If there are menopause in Group A. several different disease entities, the contributions of sex

Multivariate logistic regression analysis was steroid hormones in the initiation and progression of done with age, estradiol levels and menopausal status specific desquamative lesions are largely undefined. Volume XIV Issue IV Version I ) J DD D as covariates. Among these covariates, only serum E2 Circum-stantial clinical data are available to suggest that D

( level was showing significant independent risk for sex steroid hormones may play a role in some types of chronic desquamative gingivitis. Odd’s ratio is 13.8 desquamative gingival lesions. which mean 13.8 times more chance of association of 28 Hiyarasu Endo and Terry D. Rees in 2011 chronic desquamative gingivitis with low serum E2 level. described the standard used for the clinical appearance of desquamative gingivitis which included gingival Research V. Discussion erythema not resulting from plaque, gingival desqu- Desquamative gingival diseases were descry- amation, other intraoral and sometimes extraoral ibed in the late nineteenth century by Tomes and Tomes lesions, and complaints such as burning mouth after Medical in 1894, who noticed a singular modification of chronic eating spicy foods. Clinically, the lesion appears as fiery inflammation of gums, in which, instead of becoming red, glazed, atrophic and eroded-looking, diffuse thickened and irregular on the surface, they appeared erythema of marginal and attached gingiva with areas of 29 rather to decrease in size, assuming a very smooth, desquamation and pseudo-membrane formation. Most polished and mottled surface. The patients suffering patients with desquamative gingival lesions are middle- from this complaint were poor, middle-aged women in aged and approximately 80% are female. whom menstruation was becoming irregular or had The correct diagnosis of underlying disease in Global Journal of altogether ceased. desquamative gingivitis patients requires careful clinical

Early investigators believed gingival lesions that examination, detailed medical history, biopsy and developed in postmenopausal women were primarily the histopathological examination and the more specialized 30 result of a change in their hormonal status. However in tests such as direct and indirect immunofluorescence. the mid-twentieth century, researchers found that A number of studies suggest that oral soft chronic desquamative gingivitis was probably a manife- tissues are sensitive to hormonal imbalance. In a study station of several diseases with multiple etiologies. by Daniel, et al.8 12 patients belonging to age group Markopoulos A. K, et al. in 199627 stated that 12 % of from 21 to 67 years (10 women and 2 men) were

414 patients with desquamative gingivitis, approximately analyzed and suggested a local depletion of estrogen in

the oral tissues as a major causative agent. R.W. Women experience hormonal variations in both Wardrop, et al. in 198930 stated that oral discomfort was physiological and nonphysiological conditions. Female found to be significantly higher in peri-menopausal and sex hormones (Estrogen) have significant biological post-menopausal women who reported improvement actions that can affect other organ systems including with hormone replacement therapy. Eliasson, et al. in gingiva as reported by Salomon Amar, et al. in 1994.32 200331 in their study stated that HRT can relieve oral Parker, et. al.35 conducted polymerase chain reaction discomfort in post-menopausal women. Exogenous analysis on oestrogen and androgen receptor estrogens have been used to successfully treat desqua- expression in human gingival and periodontal tissue and mative lesions. This piece of evidence suggests that found that the gingival inflammation seen during sex some lesions are estrogen sensitive and could be due hormone imbalance in vivo could be due to secondary to the low level of serum estrogen. effects of estrogen, perhaps on the leucocytic infiltrate In normal menstruating females, the level of present in the inflamed periodontal tissue. serum estrogen is 20 - 145 pg/ml during the follicular In the current study, Group A and Group B 2014 phase, 112 - 443 pg/ml during mid-cycle phase and 20- female subjects belonged to the age group from 25 to 241 pg/ml during luteal phase. In post-menopausal 60 years of age. The age group was so determined Year females not on HRT, the level is 10 - 28 pg/ml.10 mainly to avoid observer bias and in order to obtain 32 Decreased serum estrogen level is associated more accurate result. The bias which would have with many metabolic conditions. Osteopenia, osteop- occurred due to the physiological decline in the E2 level orosis and progression of periodontitis was found following menopause was thus eliminated. Girls usually 32 attain menarche during 13- 16 years of age. There are associated with low serum E2 level. According to Bonnie J. Deroo, et al.26 estrogen has wide spread role irregularities of menstruation in some, during the early in human physiology and is implicated in the years. The minimum age selected was 25 years development and progression of numerous diseases, because the serum E2 level was expected to be which include osteoporosis, neurodegenerative dise- stabilized in this age group. The mean age of Group A ases, cardiovascular disease, insulin resistance, lupus subjects (CDG patients) was 44.52 ± 10.52 years. The erythematosus, endometriosis, obesity and various mean age of Group B control subjects was 36.32 ± 8.32 types of cancer such as breast, ovarian, colorectal, years. In the present study, it was noted that 20 % of prostate and endometrial. In many of these diseases, control subjects were having a low serum estradiol level, estrogen mediates its effect through the estrogen less than 20 pg/ml whereas 80 % were having normal or

Volume XIV Issue IV Version I receptor (ER), which serves as the basis for many more than 20 pg/ml. About 32 % of control patients were therapeutic interventions.

J above 40 years or in the pre-/peri-menopausal age. This

() Physiological and pathological response of the could be the reason for the low serum estradiol level in tissue to hormone depends on the reaction between 20 % patients in control group. hormone and its special receptors in the tissue because From the current study, it was evident that 40% for direct response to hormone, the tissues need to have of the subjects of group A were in the age group below specific receptors of that hormone. The estrogen Research 40 years and 60 % of CDG patients were above 40 years receptors are present in the non-target organs such as whereas in the control group 68 % were below 40 years gingiva. The oral soft tissues are sensitive to changes in and 32 % were above 40 years (p = 0.618). So it can be

Medical serum levels of sex steroid hormones, especially in inferred that, since patients less than 40 and more than 12 32 33 females. Chebowski, et al.3 and Amar, et al. have 40 simultaneously presented with CDG, it cannot be stated that human gingiva can metabolize estrogen and stated that age of the women had a direct correlation to contains specific high-affinity estrogen receptors. the development of CDG. Masaharu Miyagi, et al.23 hypothesized that sex In the control group, 94 % had not attained hormones may affect inflammation through their actions menopause and only 6 % had attained menopause. on the function of polymorphonuclear leukocytes Among the patients who had CDG, it was observed that

Global Journal of (PMNs) and monocytes. In their study, the chemotactic 64 % had not attained menopause and 36 % had ability of PMNs was reduced by estradiol by binding to attained menopause (p = 0.326). This clearly shows the cytoplasmic estrogen receptors. They suggested that even patients who had not attained menopause had that the altered PMN chemotaxis associated with developed CDG. Hence the variable of menopause and gingival inflammation may be due to the effects of sex related hormonal fluctuations could not be considered hormones. to be statistically significant. Maryam Seyedmajidi, et al.34 stated that In the current study, the serum E2 level of hormone receptors can be identified using ligand Group A ranged from 10 - 92 pg/ml with a mean level of bonding, auto radiography, immunohistochemistry such 18.92 ± 18.05 and that of Group B ranged from 10 - 284 as reverse transcriptase polymerize chain reaction and pg/ml with a mean level of 66.44 ± 67.48. After in situ hybridization. multivariate logistic regression analysis, it was observed

© 2014 Global Journals Inc. (US) Correlation between Estrogen Deficiency and Chronic Desquamative Gingivitis in Female Patients that 80 % of chronic desquamative gingivitis patients References Références Referencias (Group A) were having serum E2 level less than 20. It was only 20 % of the CDG patients who had normal 1. HasanS. Oral signs in mucocutaneous disorders- serum E2 level. Whereas in control group, 80 % were Report of three cases and review of literature in: with normal serum E2 level and only 20 % had Recent Researches in Medicine and Medical decreased serum E2 level (p = 0.000). From this it is Chemistry.Greece:WSEAS 2012.161-78. Available clear that there is a significant direct correlation between from:www.wseas.us/e-library/conferences/2012/Kos low level of serum E2 and the development of CDG. /MEDICAL -24. Decrease in serum E2 levels was seen in all 2. Scully C. and Porter S. R. Clinical spectrum of menopause patients with CDG. However, it is interesting desquamative gingivitis; Semin Cutan Med to note that 69 % of patients with CDG, who had not Surg.1997;16(4):308-13. attained menopause also had a decreased E2 level. 3. Glickman I and SmulowJB. Chronic desquamative This further reinforces the fact that irrespective of age gingivitis: its nature and treatment. J Periodontol. and menopause, decreased E2 levels in CDG patients 1964;35:397. 2014 has a correlation with each other. 4. ReesT.D. Vesiculo-ulcerative diseases and periodontal practice. J Periodontol.1995;66(8):747-8. Year CDG in 20% of the subjects with more than 20 5. PopovaC, DosevaV, KotsilkovK. Desquamative 33 pg/ml may be due to idiopathic cause or may be gingivitis as a symptom of different mucocutaneous associated with other disorders as it could be the first disorders. Jnl of IMAB–Annual proceeding (Scien- clinical sign and symptom in many ulcerative and tific Papers) 2007;13:2, 31- 3. vesiculobullous diseases. 6. SoukosN, Spyropoulos M. Chronic desquamative In practice, long-term steroids are the mainstay gingivitis. Etiology, clinical and histological features, for the management of CDG. Considering the side- immunopathological studies, diagnosis and treat- effects of steroids, it could be beneficial to find ment. Odontostomatol Proodos. 1990; 44(3): 151-8. alternative modalities of management for CDG. Hence, 7. Yih,WY, RichardsonL, JamesKF, AveraSP and in cases of desquamative gingivitis not responding to ZieperMB. Estrogen receptors in desquamative steroids or in patients with low serum E2 values, topical gingivitis. J Periodontol 2000;71(3):482-7 estrogen ointments or low dose hormone replacement 8. RichmanM.J and AbarbanelA.R. Effects of estradiol, therapy could be considered under the careful testosterone, diethylstilbesterol and several of their supervision of a physician or gynaecologist. derivatives upon the human oral mucous

The aim of the study was to find out if there membrane. J Am Dent Assoc.1943a;30:913-23. Volume XIV Issue IV Version I were any correlation between CDG and serum E2 level 9. RichmanM.J and AbarbanelA.R. Effects of estradiol ) J DD D D and it is clear from the results that in 80 % of patients and diethylstilbesterol upon the atrophic human ( with CDG, serum estradiol level was low. The findings in buccal mucosa with a preliminary report on the use this study should be considered as preliminary of estrogens in the management of senile gingivitis. observations because only a small number of patients J Clin Endocrinol Metabol. 1943b;3:224-6. with CDG were analyzed. Further randomized control 10. ZiskinDE and ZegarelliEV.Chronic desquamative Research trials are merited to establish the linkage between low gingivitis: A reprt of 12 cases. Am J Oral serum estradiol (E2) level and CDG. It would also help Surg.1945;31(1):C1-33. to assess treatment outcomes with estrogen 11. Engel M. B, Harold G, Ray H. G, Orban B. The Medical supplements for patients with CDG. pathogenesis of Desquamative gingivitis: a disturbance of the connective tissue ground VI. Conclusion substance. J Dent Res.1950;29(4):410-8. 12. Kindler T. Congenital poikiloderma with traumatic Desquamative gingivitis is not a disease but a bulla formation and progressive cutaneous atrophy. reaction pattern of gingiva which conceals other Br J Dermatol.1954;66:104-11. pathologic diseases. Hormonal imbalance has been

13. McCarthy F. P, Mc Carthy P. L, and Shklar G. Global Journal of suggested as one of the etiology. In the present study, Chronic desquamative gingivitis: Reconsideration. the level of circulating estradiol (E2) was found to be Oral Surg.1960;13:1300. decreased in chronic desquamative gingivitis.Further 14. Löe H, Silness J. Periodontal changes in pregnancy. investigative studies to find out the effect of exogenous I. Prevalence and severity. J Periodontal. 1965; estrogen in the management of desquamative gingivitis 36:533-51. could be done. In this study, the severity of CDG and 15. Kullander S, and Sonesson B. Studies on saliva in serum level of E2 was not compared. This could also be menstruating, pregnant and post-menopausal done in future studies. women. Acta Endocrinol (Copenh).1965;48:329-36. 16. Jensen E. V, Suzuki T, Kawashima T, Stumpf W. E, Jungblut P. W, and Desombre E. R. A two-step

mechanism for the interaction of estradiol with rat 32. ChlebowskiR.T, Wactawski-WendeJ, RitenbaughC, uterus. Proc Natl Acad Sci USA.1968;59(2):632-8. et al. Estrogen plus progestine and colorectal 17. GorskiJ, Toft D, Shyamala G and NotidesA. cancer in postmenopausal women. N Engl J Hormone receptors: Studies on the interaction of Med.2004;350(10):991-1004. estrogen with the uterus. Recent Prog Horm 33. AmarS, and ChungK.M. Influence of hormonal Res.1968;24:45-80. variation on the periodontium in women. Periodontol 18. Kalkwarf K. L. Effects of oral contraceptive therapy 2000.1994;6(1):79-87. on gingival inflammation in humans. J 34. MajidiS.M, ShafaceS, Azhdari M, KhafriS, SiadatiS, Periodontol.1978;49(11):560-3. Mehdizadeh M. Immunohistochemical expression of 19. Pankhurst C. L, Waite I. M, Hicks K. A, Allen Y, and estrogen and progesterone receptors in epulis Harkness R. D. The influence of oral contraceptive fissuratum. J. Res. Med. Sci.2013;15(1):19-23. therapy on the periodontium- duration of drug 35. Parkar M. H, Newman H. N, and Olsen I. Polym- therapy. J Periodontol.1981;52(10):617-20. erase chain reaction analysis of estrogen and

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J peripheral polymorphonuclear leukocytes and () monocytes. J Periodontol.1992;63(1):28-32. 25. Ciocca D. R and Roig L. M. L. Estrogen receptors in human nontarget tissue: biological and clinical implications. Endocrine Rev.1995;16(1):35-62.

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Implant Surface Micro-Design By Ashu Sharma, G.R.Rahul, Soorya Poduval & Rahul Sharma Sharma Dental Hospital, India Abstract- The application of implants for dental and orthopedic surgery has increased rapidly within the past few decades. In craniomaxillofacial surgery, different implant systems have been applied, for example, for dental and bone replacement or osteosynthesis plates and screws. These implants may be made of pure titanium or a titanium alloy, usually titanium-aluminum- vanadium (Ti-6Al-4V). The surface can he turned or Machined or a coating may cover the metal base. The reason for treating the implant surface is to obtain maximum bone-implant contact and bone-implant stability and to shorten the healing time for earlier loading. The crucial aspect of pure titanium implants is the development of titanium oxide on the surface. This oxide and other known coatings for implant material do not have high wear resistance. This article thus aims to review Implant Surface Micro-design its rationale, various surface’s physical and chemical properties, different types of implant surface treatments, optimum roughness of oxidized implants and controversies associated with various implant topographies. The recent advances like nanotechnology are also included. Keywords: implants, implant topography, implant surface micro-design, implant surface treatments. GJMR-J Classification: NLMC Code: WU 158

ImplantSurfaceMicro-Design

Strictly as per the compliance and regulations of:

© 2014. Ashu Sharma, G.R.Rahul, Soorya Poduval & Rahul Sharma. This is a research/review paper, distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License http:// creativecommons. org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Implant Surface Micro-Design

Ashu Sharma α, G.R.Rahul σ, Soorya Poduval ρ & Rahul Sharma Ѡ

Abstract- The application of implants for dental and orthopedic Titanium, preferably commercially pure titanium, surgery has increased rapidly within the past few decades. In became the standard for endosseous implants. Actually craniomaxillofacial surgery, different implant systems have titanium is a very reactive material that would not been applied, for example, for dental and bone replacement or become integrated with tissues. However, its instant- osteosynthesis plates and screws. These implants may be aneous surface oxidation creates a passivation layer of made of pure titanium or a titanium alloy, usually titanium- aluminum-vanadium (Ti-6Al-4V). The surface can he turned or titanium oxides, which have ceramic- like properties, Machined or a coating may cover the metal base. The reason making it very compatible with tissues. 2014 for treating the implant surface is to obtain maximum bone- implant contact and bone-implant stability and to shorten the II. Rationale for a Dynamic Implant Year healing time for earlier loading. The crucial aspect of pure Surface titanium implants is the development of titanium oxide on the 35 surface. This oxide and other known coatings for implant Oral implant is an alloplastic material or device material do not have high wear resistance. that is surgically placed in to the oral tissue beneath the This article thus aims to review Implant Surface mucosal or periosteal layer or within the bone for Micro-design its rationale, various surface’s physical and functional, therapeutic, or esthetic purposes1. More chemical properties, different types of implant surface needs to be known about the optimal situation of the treatments, optimum roughness of oxidized implants and connection between an artificial material and the controversies associated with various implant topographies. tissues-what type of material that gives the best tissue The recent advances like nanotechnology are also included. response and what type of surface is preferred by the Keywords: implants, implant topography, implant bone cells or the cells in the soft tissue. If this is known, surface micro-design, implant surface treatments. the response of the bone or soft tissue can be predicted I. Introduction when the implants are installed into the jaws. There is some information and understanding of the effect of he success and predictability of osseointegrated design and toxicology of the implants, surgery

dental implants have forever changed the techniques, effect of movement of the implant during the Volume XIV Issue IV Version I

philosophy and practice of dentistry and, perhaps healing period and biodegradation. Understanding is ) J DD D T D more than any other specialty, Prosthodontics has lacking, however, of the relationship between the events ( changed dramatically. In the late 1950’s, Per-Ingvar that occur at the implant surface and the effect the Branemark, a Swedish professor in anatomy studying implant material has in the tissue and the biocom- blood circulation in bone and marrow, developed patibility of the material2. through a serendipitous finding in the history of medicine: he predictably achieved an intimate bone-to- a) The bone-implant interface Research implant apposition that offered sufficient strength to Bone tissue is a living organ, which can be cope with load transfer. He called the phenomenon described as a natural composite composed of an Medical “osseointegration”.. organic matrix strengthened by an inorganic calcium Since that time, millions of patients have been phosphate (CaP) phase. The extracellular organic matrix treated worldwide using this technique. The implants (ECM) of bone consists of 90% collagenous proteins used sometimes had different geometries and surface and 10% non-collagenous proteins. Regarding the characteristics. A key element in the reaction of hard inorganic component, the most abundant mineral phase and soft tissues to an implant involves the implant’s in human bone is carbonate rich hydroxyapatite (with a 3 surface characteristics, that is, the chemical and carbonate content between 4% and 8%) . physical properties. Quest continued for a material with When an implant is installed in a jaw, a series of Global Journal of a surface property which enhances bone apposition at reactions take place on the implant surface. The implant the implant surface in an osteoconductive manner. The is exposed to a series of different ions, to polysacc- quest was for a biocompatible if not bioactive surfaces, harides, carbohydrates and proteins as well as to such achieved through additive or subtractive process. cells as chondroblasts, fibroblasts and osteob-lasts that react with the surface (Figure:1 and 1a)2,3. The initial Author α: Sharma Dental Hospital. Machhiwara, Ludhiana, Punjab. reactions between the tissue constituents and the India-141115. e-mail: [email protected] implant surface govern the further reactions and Author σ ρ Ѡ: Dept. of Prosthodontics, Bangalore Institute of Dental Sciences and Research Center, 5/3 Hosur Main Road, Opposite determine the biological activity of the surface and the Lakkasandra Bus Stop. Wilson Garden, Bangalore 560027. India. further cell responses to the surface. This tissue

response depends on the nature of the surface and its onto the material 4-7. this further strongly influences the chemical properties, which influences the nature of the cell responses on the surfaces. subsequent composition of the protein film that adsorbs 2014 Year

Figure 1 : After implantation, the biomaterial is exposed to a series of different tissue constituents that react with the surface. The type of reaction that occurs probably influences the further cell reactions and finally the tissue- biomaterial connection. Ig: immunoglobulins Volume XIV Issue IV Version I J ()

Research Figure 1(a) : Schematic representation of events consecutively taking place at the titanium surface after implantation into living bone tissue. Water binds to the surface, followed by incorporation of hydrated ions, adsorption and desorption of proteins, eventually leading to cell attachment. After differentiation, mature osteoblasts produce the Medical extracellular matrix (ECM)

b) Osseo-integration versus Osseo -coalescence III. Physical Properties The term osseointegration largely refers to the physical integration or mechanical fixation of an implant Several authors have discussed the dimension in bone. The interlocking provides mechanical resist- of the ideal roughness that would provide increased ance to forces such as shear experienced in “pull-out” retention and an improved bone response. The

Global Journal of and “torque-out”. With purely physical interaction, roughness can be considered on different levels: however, the interface would not be able to withstand macrostructural, microstructural and ultrastructural, and even moderate tensile forces. The term osseoco- roughness on these different levels probably has alescence has been proposed to refer specifically to different effects on the living tissues. It has been chemical integration of implants in bone tissue. The term established in the literature based on several studies applies to surface reactive materials, such as calcium that, to gain complete growth of bone into a material’s phosphates and bioactive glasses, which undergo irregularities, these need to be at least 100 µm in size. reactions that lead to chemical bonding between bone Growth of bone into cavities or pores of this size will give and biomaterial. With these materials, the tissues a mechanical interlocking of the material with bone. This effectively coalesce with the implant8. was demonstrated by Bobyn et al. in studying cobalt- based alloys with pore sizes of 50- 400 µm9, Bone

© 2014 Global Journals Inc. (US) Implant Surface Micro-Design ingrowth was also observed by Clemow et al. when this due to bone in growth, in vitro cell studies indicate that group studied porous coated Ti&l,V femoral implants this property of the surface influences the function of the with pore sizes ranging from 175 to 235 µm10. cells, the matrix deposition and the mineralization12. Cells seem to be sensitive to microtopography and a) Surface Microstructure appear to be able to use the morphology of the material This can vary considerably depending on the for orientation and migration13. The maturation of the surface treatment of the implant. Variation of the surface cells also affects the response to the surface roughness, microstructure has been reported to influence the stress which is in agreement with earlier observations that distribution, retention of the implants in bone and cell indicated that chondrocytes are affected differently by responses to the implant surface. The implants with local factors such as vitamin D and transforming growth rough surfaces have improved bone response, with factor p depending on the stages of maturation of the bone trabeculae growing in a perpendicular direction to cells14,15. Microtopography may therefore be one factor the implant surface. An improved retention in bone has that influences the differentiation of mesenchymal cells also previously been reported after implantation of into fibroblasts, chondrocytes or osteoblasts. Based on 2014 rough-surfaced implants2. these studies, it can be hypothesized that osteogenesis

Surface roughness on a smaller scale was, Year may be favored by vascular in growth, whereas a limited however, found to be important for integration of the vascular in growth may induce chondrogenesis. bone with the implant surface11. Although surface 37 Figures: 2 and 4. roughness on a micrometer scale gives some retention Volume XIV Issue IV Version I ) J DD D D

(

Figure 2 : Scanning electron micrograph with high resolution (x503) of the surface of a machined, threaded implant (Nobel Biocare Mark II) Research Medical Global Journal of

Figure 3 : Scanning electron micrograph with high resolution (x503) of the surface of a titanium plasma-sprayed threaded implant (IT1 Bonefit)

38 Figure 4 : Scanning electron micrograph with high resolution (X503) of the surface of a titanium dioxide-blasted threaded implant (Astra Tech TiO-blast) The ideal surface roughness for bone implants recognizes the surface prepared by the course particle, on a micrometer scale probably depends on the as a smooth surface, whereas the 25-pm particles distribution of cortical or cancellous bone and on the creates a rough surface that is identified by the osteo- level of loading to the implants.2 The rugofile bone cells blasts2 Figure: 5. Volume XIV Issue IV Version I J () Research

Medical

Figure 5 : Bone cells exposed to a medium rough and a very rough surface. The rugofile bone cells may recognize the very rough surface (right) as a smooth surface, whereas the medium rough surface (left) is recognized as a trough rough surface by the osteoblasts Osteoblasts respond to microarchitectural to growth factors and cytokines in a surface-dependent features of their substrate. On smooth surfaces (tissue manner. On rougher surfaces, the effects of regulatory Global Journal of culture plastic, tissue culture glass, and titanium), the factors like 1α, 25(OH)2 D3 or 17β-estradiol are cells attach and proliferate but they exhibit relatively low enhanced. When osteoblasts are grown on surfaces expression of differentiation markers in monolayer with chemistries or micro architectures that reduce cell cultures, even when confluent. When grown on attachment and proliferation, and enhance differe- microrough Ti surfaces with an average roughness of 4- ntiation, the cells tend to increase production of factors 7 μm, proliferation is reduced but differentiation is like TGF β1 that promote osteogenesis while decreasing enhanced and in some cases,as it is synergistic with the osteoclastic activity. Thus, on microrough Ti surface, effects of surface microtopography. In addition, cells on osteoblasts create a microenvironment conducive to

microrough Ti substrates form hydroxyapatite in a new bone formation16. Figure:6. manner that is more typical of bone than do cells cultured on smooth surfaces. Osteoblasts also respond

Figure 6 : Schematic diagram showing the effects of rough microtopography on production of paracrine factors by osteoblasts during peri-implant bone formation. Osteoblasts synthesize osteoid on the implant surface as well as on 2014 the normal bone surface. Levels of latent TGF-β1 are increased in the extracellular matrix, as well as in the Year extracellular fluid. Once activated, the growth factor can stimulate osteoblast proliferation, extracellular matrix synthesis and alkaline phosphatase activity (+). At the same time, active TGF-β1 inhibits osteoclastic activity (-). 39

Osteoblasts also produce elevated levels of 1,25 dihydroxyvitamin D3 (1,25(OH)2D3) on rough surfaces. 1, 25(OH)2 D3 promotes osteoclast formation due to fusion of monocytes and acts on osteoblasts promoting their differentiation. 1α, 25(OH)2 D3 also stimulates matrix calcification through rapid activation of Ca2+ ion deposition b) Surface Ultrastructure the method of manufacture and not the resultant

Although micro-roughness seems to be an surface. important characteristic for tissue response to bioma- Rough surfaces can be divided into three levels terials, there are also observations that indicate a depending on the scale of the features: macro-, microbiological response to irregularities on the nanometer and nano-sized topologies. The macro level is defined level. Larsson et al. studied the biological effect of for topographical features as being in the range of 20 changing the oxide thickness of titanium implants from millimeters to tens of microns . This scale is directly an electropolished level, to thick oxide layers formed by related to implant geometry, with threaded screw and anodization. By this treatment the surface changes from macro porous surface treatments giving surface an amorphous metal surface with a noncrystalline oxide roughness of more than 10μm. Numerous reports have Volume XIV Issue IV Version I to a polycrystalline metal surface with a crystalline oxide shown that both the early fixation and long-term ) J DD D D

17 layer . mechanical stability of the prosthesis can be improved ( by a high roughness profile compared to smooth Analysis of these surfaces at a high resolution surfaces21. level demonstrated that the new surface was The high roughness resulted in mechanical heterogeneous with mainly smooth areas of thick oxide interlocking between the implant surface and bone on but separated with porous regions on a nanometer level. Research growth. However, a major risk with high surface This observation of an increased roughness after roughness may be an increase in peri-implantitis as well anodization of titanium was in line with earlier as an increase in ionic leakage. A moderate roughness transmission electron microscopic studies demon- Medical of 1–2 m may limit these two parameters22. The microt- strating increased pore sizes with increased oxide μ opographic profile of dental implants is defined for thickness18. surface roughness as being in the range of 1–10μm. Implants with this thick, heterogeneous oxide seemed to have a slightly improved response in bone, IV. Chemical Properties particularly in the first weeks after implantation. a) The surface chemistry of the implants c) Smooth versus Rough Surfaces The chemical properties of the biomaterial Global Journal of Surface quality of an oral implant can be surface play an important role for the tissue responses subdivided in to mechanical, topographic, and physic- elicited by the material. This is at least one main reason chemical properties19. Surface topography is charac- why the tissues responds differently to different teristic of the preparation process. Variations in the materials.2 A material with a surface that is accepted by roughness and porosity can be categorized in function the tissue seems to exhibit improved integration with of the surfacing process. The current state of bone, either due to passive growth, leading to a tight information regarding implant surface topography has connection between implants and bone, or by provided clinicians with confusing options. Machined stimulation that probably leads to a bone-implant implants are not smooth, and not all rough implant bonding. This is probably the case with the two main surfaces are equivalent. Surfaces often are identified by materials used in dental implants, hydroxyapatite and

2 The biological activity of the TiO probably also titanium. The calcified parts of the bone consists of 2 influences the protein adsorption to titanium. In an in hydroxyapatite (or rather carbonated apatite), and vitro study, serum proteins seemed to adsorb to titanium introducing this substance as an implant material often 23 dioxide by the same mechanisms as to hydroxyapatite gives favorable responses in the bone. through calcium binding24. The surface characteristics of The biological effects of modifying the biomaterial surface have also been elaborated24-25. In an TiO2 probably change from an anionic to a cationic attempt to study the effect of the oxide layer of titanium state by the adsorption of calcium to the surface. This on calcium-phosphate precipitation, titanium-dioxide will subsequently increase its ability to adsorb acidic (TiO2) and powder of oxidized and nonoxidized titanium macromolecules, such as albumin, a property 26-27 were introduced into an in vitro nucleation test system24. demonstrated for hydroxyapatite . In this system they found that titanium powder enhances Fluoride ions have documented activity in bone. calcium phosphate nucleation only after prolonged pre- This element is known to form fluoridated hydroxyapatite or fluorapatite with improved crystallinity and better incubation in an aqueous buffer, or after autoclaving. resistance to dissolution than hydroxyapatite28. Fluoride

2014 These treatments enhance the growth of the oxide layer. This observation indicated that the oxide content, or also enhances the incorporation of newly formed

Year structure, is required for titanium to act as a nucleation collagen into the bone matrix and increases the rate of substrate. Even more effective nucleation was observed seeding of apatite crystals as well as increasing 40 when pure TiO2 was used as a nucleation substrate. trabecular bone density and stimulating osteoprogenitor 29,30. The nucleation capacity and formation of calcium cells number in vitro Figure-7 and 8. phosphate precipitates is related to the biocompatibility of titanium, and enhanced nucleation capacity may indicate improved biocompatibility.2 Volume XIV Issue IV Version I J ()

Research Figure 7 : Scanning electron micrograph of a fluoride-modified implant after the push-out procedure. The implant is partly (right side) covered by bone that is firmly fixed to the implant surface, which indicates bonding between the titanium implant and bone Medical Global Journal of

Figure 8 : A possible mechanism between the fluoride-modified titanium and bone. Oxygen in phosphate may replace the fluoride and bind to titanium to create a covalently binding between bone and titanium. The fluoride ions which are released by this process may thus catalyze the new bone formation in the surrounding tissue

V. Diferent Types of Implant Surface II. Removal of material - Particle jets and/or acid etching Treatments III. Modification of material - The implant surface can The desired implant surface can be achieved by be modified without either adding or removing addition of material over the surface, removal of material material. (Electron beam, thermal treatment, laser from the surface or modification of the surface material. treatment, and ion implantation) Some of the examples are: I. Addition of material - Titanium plasma spray (TPS, TiO2); coating with hydroxyapatite (HA). a) Addition of Material (Additive Methods)

Chemical substances are successfully added over the surface. Some of the materials used for this purpose include:

1. ydroxyapatite. 4. Zirconium. 7.Tantalum chloride. 2.Titaniumoxide. 5. Fluoride. 8. Magnesium. 3. Titanium nitrite. 6.Nano structured Al. 9.Biologic substances. 2014 Apart from the above mentioned chemical substances, the following biologic materials can also be added over the

surface to obtain the desired surface properties: Year

A. RhBMP-2. D. RGD peptides. G. Vitronectin. 41 B. Growth factors. E. Human mesenchyme. H. Laminin.

C. Type 1 collagen. F. Fibronectin. I. Human albumin.

J. Chitosan. b) Removal of Material (Subtractive Methods) This technique involves creation of surface roughness by various methods like: 1. Sand Blasting. 4. Acid Etching. 6. Laser Etching. 2. Machining. 5. Dual Acid Etching. 7. Micro arc oxidation. 3. Micro machining. c) Modification of Material 1. Surface Wetting. 3. Electron beam. 5. Ion implantation. 2. Plasma cleaning. 4. Thermal treatment.

VI. dditive ethods of urface of a decade ago but reportedly exhibit reduced A M S Volume XIV Issue IV Version I wettability, which could potentially negatively affect Treatment ) J DD D tissue adhesion and long-term clinical outcome. D

( a) Hydroxyapatite coating Bone morphogenetic proteins (BMP s) play a Hydroxyapatite is a calcium phosphate ceramic crucial role in cell ingrowth and differentiation in a variety that is an osteophilic, osteoconductive, bioactive of cell types, including osteoblasts32. Because of their coating, which is totally biocompatible and becomes an beneficial effects, BMP s have been used to accelerate integral part of living bone tissue. Hydroxyapatites and healing after implant placement. Apatite is considered a Research tricalcium phosphates have an excellent grade of 33 suitable carrier of BMP-2 and the incorporation of acceptance, and these materials may be more rapidly BMP-2 into the apatite layer of a titanium implant may incorporated in bone than commercially pure titanium. Medical enhance its osteoinductive properties. Hydroxyapatite coating over titanium has enjoyed a rapid growth because of its inherent biomaterial i. Methods of HA Coating properties that some consider an advantage over Conventional plasma spraying, flame spraying, uncoated surgical titanium. Hydroxyapatite (HA) coating and chemical techniques have all been investigated as has become popular for load bearing dental implants techniques for producing a thinner HA coating on a because it elicits a faster bony adaptation, absence of metal substrate. The bond formed between HA coatings fibrous tissue seams, firmer implant bone attachment, and the metallic substrate by the spraying method, Global Journal of reduced healing time, increased tolerance of surgical formed primarily through mechanical interlocking, is not inaccuracies, and inhibition of ion release31. strong enough. Additionally, the spraying method is The first clinical use of hydroxyapatite (HA) as a unsatisfactory for applying a thinner, uniform HA coating coating on dental implants began in February 1984, with on implants because of their complicated shapes. On the results showing many benefits over the no coated the other hand, electrochemical methods, electrop- implants31. Later, many researchers conducted studies 0horetic techniques in particular, seem attractive for and obtained promising results. forming HA coatings on titanium implants with compli- Contemporary plasma-sprayed hydroxyapatite cated shapes. However, the bond between the coating (HA) coatings with high crystalline content are much and the metal substrate is significantly weak. Magnetron more resistant to in vivo degradation than HA coatings sputter coating and Ion Beam sputtering techniques for

coating HA on implant surfaces have been tried with of cellular function and differentiation and on suitable varying rates of success. Hydroxyapatite can be coated surface modification techniques36. by plasma spraying. In this technique, powdered e) Bio- molecules crystalline hydroxyapatite is introduced and melted by 37 the hot, high velocity region of a plasma gun and i. Laminins propelled onto the metal implant as a partially melted Laminins are major proteins in the basal lamina, ceramic. a protein network foundation for most cells and organs. They are an important and biologically active part of the b) Plasma Sprayed Titanium basal lamina, influencing cell differentiation, migration, Hahn and Palich (1970) first developed titanium adhesion as well as phenotype and survival. surfaces by plasma spray techniques and reported an ii. Fibronectin37 enhanced bone ingrowth in those implants. The plasma Fibronectin is a high-molecular weight (~440 sprayed titanium surfaces exhibit a porous surface with 34 kDa) extracellular matrix glycoprotein that binds to

2014 macro irregularities . membrane-spanning receptor proteins called integrins. i. Macro-irregularities In addition to integrins, fibronectin also binds Year Macro-irregularities in an implant include extracellular matrix components such as collagen, fibrin 42 macroscopic threads, fenestrations, pores, grooves, and heparan sulfate proteoglycans. steps, threads, or other surface irregularities that are It is involved in cell adhesion, growth, migration visible. The idea is to create mechanical interlocking and differentiation. Cellular fibronectin is assembled into between implant and bone at the macro level. the extracellular matrix, an insoluble network that ii. Method of Plasma spraying separates and supports the organs and tissues of an Powdered Titanium is melted at a temperature organism. of 15,000 degrees and is sprayed on to the surfaces of iii. Vitronectin the implant at a very high velocity of 600 m/sec through Vitronectin is an abundant glycoprotein found in argon plasma associated with a nozzle. The diameters serum the extracellular matrix and promotes cell of the sprayed particles are around .04 to .05mm adhesion and spreading. thickness. When observed microscopically the coatings Vitronectin serves to regulate proteolysis show round or irregular pores that are interconnected initiated by plasminogen activation. Additionally with each other. The surface of the implants where they Vitronectin is a component of platelets and is thus condense and fuse together, forming a film about 30 μm

Volume XIV Issue IV Version I involved in hemostasis. Vitronectin contains an RGD thick. The thickness must reach 40–50 μm to be sequence which is a binding site for membrane bound J uniform. The resulting TPS coating has an average integrins, e.g. the Vitronectin receptor, which serve to () roughness of around 7 μm, which increases the surface anchor cells to the extra cellular matrix. area of the implant. iv. RhBMP-2 c) Anodic Spark Deposition BMP‘s are Bone morphogenetic proteins. They are members of growth and differentiation protein

Research Anodic spark deposition techniques have been ― effectively applied to achieve a microporous family. They are homodimeric, glycosylated proteins that morphology on metals. Recently, a new electrochemical are highly conserved across species. They are found to

Medical process has been developed to improve further the be osteoinductive in animals and humans. mineralization potential, mechanical stability, and They are supposed to promote bone induction corrosion resistance of the ceramic coating obtained by increasing Chemotaxis and increasing the with anodic spark deposition. Electrochemically treated proliferation and differentiation of bone forming cells titanium showed promising results and was able to from undifferentiated mesenchymal cells. introduce substantial improvements in achieving fast They induce the formation of both trabecular and stable osseointegration of implants in osteopenic and woven bone. The formed bone remodels based on 35

Global Journal of sheep bone . the demand at the particular site. The delivery of BMPs is aimed at local administration, which is in favor for d) Biologic Coatings Puleo and Nanci (1999) emphasized the impor- coating the implant surfaces.

tance of biochemical methods of surface modification v. Bio molecules and Implants as an alternative or adjunct to morphologic approaches. The proportions of these biologic molecules Biochemical methods are aimed at control of the tissue- and the presence of other lesser-known components implant interface by the immobilization and/or delivery of seem to vary with the anatomic location and specific proteins, enzymes, or peptides for the purpose of function of the individual basement membrane. Ultra inducing specific cell and tissue responses. They rely on structural data provided by Swope and James (1981) current understanding of the biology and biochemistry indicate that hemidesmosomes formed on Vitallium

© 2014 Global Journals Inc. (US) Implant Surface Micro-Design implants in monkeys after 2 days and became well differences in the mean bone-to-implant contact established after 3 days38. between the various implant surfaces were observed in However, more recently published data dispute cortical as well as in cancellous bone after 1 and 3 these findings, indicating that hemidesmosomal months of implantation43. contacts were found only on apatite and polystyrene ix. Growth factor coatings substrates. Growth factors are signaling proteins that vi. Amino acid sequence RGD promote replication, differentiation, protein synthesis In a goat femur wound chamber model, and /or migration of appropriate cell types. In case of Bernhardt et al. (2005) compared bone-to-implant endosseous titanium implants, an enhanced contact on uncoated titanium implant surfaces with RGD proliferation and differentiation of undifferentiated peptide-coated surfaces. After 5 and 12 weeks of mesenchymal cells osteoprogenitor cells and preoste- healing, no significant effect of RGD coating on the oblasts into osteoblasts may enhance bone healing mean bone-to-implant contact percentages was (Chappard et al.1999)44. observed39. These results contradict the findings of Therefore, the rational to coat titanium implants 2014 Schliephake et al. (2005b) and Rammelt et al. (2006)40- with locally acting growth factors is the assumption that Year 41. the release of these growth factors might improve the Schliephake et al. (2005b) compared, in the remodeling process at the bone–implant interface, 43 mandible of dogs, machined titanium implant surfaces leading to enhanced bone response (De Jonge et al. (Ti) with RGD-coated implant surfaces. RGD coatings 2008)45. were achieved either with low RGD concentrations (100 x. Bone Morphogenic Proteins m mol/ml) (RGD low‘) or with high RGD concentrations A particular class of growth factors, BMPs, has (1000 m mol/ml) (RGD high). After 1 month of healing, shown considerable potential to stimulate bone bone-to-implant contact was significantly higher for RGD formation both in extra skeletal sites (Yamazaki et al. high compared with Ti. After 3 months of healing, bone- 1996; Yoshida et al. 1998) and in defect models in to-implant contact was significantly higher for RGD high 40 different species (Zellin & Linde 1997; Teixeira and Urist and for RGD low compared with Ti . 1998)46-48. BMPs originate from the TGF-b family and vii. Collagen and collagen mimetic peptides include at least 18 different proteins (Reddi 1995)49. As The in vivo osteoconductive potential of type I BMP-2 possesses high osteoinductive potential (Laub et collagen, type III collagen and collagen mimetic peptide al. 2001), it was considered to be an interesting

sequences as coating for titanium implants was candidate growth factor to coat titanium implants. Volume XIV Issue IV Version I investigated in the publications of Rammelt et al. While BMP-2 is used more commonly, BMP-4 is ) J DD D D

(2004,2006,2007), Bernhardt et al.(2005), Schliephake et also considered as a candidate growth factor that might ( 39-42 al.(2005a,2005b) and Reyes et al.(2007) . improve the remodeling process at the bone–implant In the proximal tibial metaphysis of rats, Reyes interface (Stadlinger et al. 2008)50. Besides promoting et al. (2007) compared the mechanical anchorage as bone formation BMPs stimulates recruitment, well as bone-to-implant contact of machined proliferation, and differentiation of osteoclasts as well Research c.p.titanium implant surfaces (Ti)with either bovine type I (Chen et al.2004)51. collagen (Col-I) or glycine–phenyl alanine–hydroxy xi. Non-BMP growth factors proline–glycine–glutamate–arginine (GFOGER; a Besides BMPs, other growth factors loaded Medical collagen mimetic peptide sequence)-coated implant onto titanium implant surfaces were tested in animals as surfaces. After 4 weeks of healing, the mean pull-out potential agents to enhance osseointegration (De Jonge forces were around 35N for GFOGER, 20N for ColI and et al.2008)45. 35N for Ti. GFOGER was statistically higher compared Examples are: with ColI or Ti, but the values for Col I were not statistically higher compared with Ti. The authors 1. Growth hormone (GH) (Blom et al.1998)52. concluded that both coatings (GFOGER and ColI) 2. Platelet-derived growth factor (PDGF), combined enhanced bone repair and implant integration. with insulin-like growth factor-1 (IGF-1) (Stefani et Global Journal of al. 2000)53. viii. Collagen composite coating with CaP In the mandible of dogs, Schliephake et al. 3. Platelet rich growth factors (PRGFs)(Fuerst et al. 2003)54 (Eduardo A Anitua 2006)55 (2003) compared bone-to-implant contact between 4. TGF-b2 (De Ranieri et al.2005)56. titanium alloy implants with a polished surface (Ti), 5. Fibroblast growth factor-fibronectin fusion protein collagen-coated (Col), mineralized (hydroxyapatite) (FGF-FN) (Park et al. 2006)57. collagen-coated (Col/HA), sequentially hydroxyapatite- collagen-coated (Col/sew HA) and hydroxyapatite- xii. Bone-like coatings coated titanium surfaces (HA). Animals were sacrificed A method to self-assemble and mineralize after 1 and 3 months of healing. No significant collagen gel and to precoat a bone-like layer of

mineralized collagen immobilized on titanium implant have interfered with the osseointegration of the implants. surfaces has been demonstrated. The mineralized layer Moreover, this chemical heterogeneity of the implant was found to promote cellular activity, indicating surface may decrease the excellent corrosion resistance potential for more efficient bone remodeling at the of titanium in a physiological environment63. implanttissue interface. This may promote and/or c) Acid-etching accelerate osseointegration58. Etching with strong acids such as HCl, H2SO4, VII. Removal of Material (Subtractive HNO3 and HF is another method for roughening titanium dental implants. Methods) Acid etching produces micro pits on titanium Implant Surfaces can be roughened by various surfaces with sizes ranging from 0.5 to 2nm in material removing techniques. Of which the most diameter.64 Acid- Immersion of titanium implants for common methods are: several minutes in a mixture of concentrated HCl and H2SO4 heated above100 ◦C (dual acid-etching) is 2014 1. Sandblasting. 2. Acid etching. employed to produce a micro rough surface. This type Year 3. Machining. of surface promotes rapid osseointegration while maintaining long-term success over 3 years 65. 44 a) Machining Enhanced bony anchorage was noted to dual acid- The machining of Cp titanium imparts a surface etched implants as compared to machined implants66. roughness that is distinct from smooth or polished Acid-etched implants showed significantly surfaces. The machining method is an important higher mineral apposition rates compared to acid- determinant of the resulting surface. Different surfaces etched, phosphate coated implants67. are imparted by machining or subsequent modification. Electro polishing of machined components can further d) Sand Blasted and Acid etched (SLA) surface reduce variations measured at the surface, but such Among the various techniques to produce a surfaces are not well osseointegrated. Creating micro rough titanium surface, the combination of sand topographic variation from the mean surface plane can blasting and acid etching can be used. These surfaces be achieved by abrasion (TiO2 blasting or showed enhanced bone apposition in histomorph- soluble/resorbable blasting materials [S/RBM]), blasting, ometric studies, and higher torque values in biomec- blasting and etching (alumina oxide and H2SO4/HCl), hanical testing. Based on these experimental studies, anodizing, cold working (dimpling), and different clinical studies were initiated to load SLA implants after Volume XIV Issue IV Version I chemical etching methods (H2SO4/HCl)59-61. Bone to a reduced healing period of only 6 weeks. The clinical

J implant contact is one of the important factors for examination up to 3 years demonstrated favorable

() 68. osseointegration. Bone to implant contact is higher for results, with success rates around 99% osteotite surfaces when compared to machined e) Chemically Modified SLA Surface: SLActive 62 surfaces . SLActive is based on the scientifically proven SLAR topography (M. de Wild 2004.). In addition, it has

Research b) Grit Blasting Another approach for roughening the titanium a fundamentally improved surface chemistry. The surface consists in blasting the implants with hard chemically active, hydrophilic SLActive surface promotes the initial healing reaction, allowing for direct Medical ceramic particles. The ceramic particles are projected through a nozzle at high velocity by means of cell interaction at the initial stage of the osseointegration compressed air. Depending on the size of the ceramic process. Bone formation is immediately initiated particles, different surface roughnesses can be resulting in earlier secondary stability and reducing the produced on titanium implants. The blasting material critical dip. should be chemically stable, biocompatible and should D.Buser et al studied the modified SLA surface not hamper the osseointegration of the titanium produced by rinsing under N2 protection and storing in an isotonic NaCl solution. They demonstrated that the

Global Journal of implants. Various ceramic particles have been used, such as alumina, titanium oxide and calcium phosphate modSLA surface promoted enhanced bone apposition 69 particles. Alumina (Al2O3) is frequently used as a during early stages of bone regeneration . blasting material and produces surface roughness Michael M. Bornstein et al showed that Dental varying with the granulometry of the blasting media. implants with a mod SLA surface (SLActive) However, the blasting material is often embedded into demonstrated statistically significant differences for the implant surface and residue remains even after probing depths and clinical attachment level values ultrasonic cleaning, acid passivation and sterilization. compared to the historic control group, with the mod Alumina is insoluble in acid and is thus hard to remove SLA surface implants having overall lower probing 70 from the titanium surface. In some cases, these particles depths and clinical attachment level scores . Figure-9. have been released into the surrounding tissues and

45 Figure 9 : SLA and SLActive. (F. Rupp, L. Scheideler, N. Olshanska, M. de Wild, M. Wieland, J. Geis-Gerstorfer J. Biomed. Mater. Res. A. 2006;76(2):323–334)

VIII. Modification of Material roughness and increased bone to implant contact 72. (BIC) a) Ion Implantation CO ion implantation is a new surface treatment c) Optim al Surface Properties Surface properties of implants directly influence designed to improve implant bone integration by modifying the chemical structure of the implant surface bone responses. Thus, irrespective of the surface at the atomic level without adding or removing material. modification technology used, detailed surface chara- This is a high vacuum physical technique (<10-4Pa) in cterization of an implant is important. Based on the bone response in the present study, which was expressed as which the surface of a material is bombarded with previously selected and accelerated ions that become a function of quantitative changes in the surface oxide integrated or implanted within the outer atomic layers of properties, the following appear to be the optimum Volume XIV Issue IV Version I the surface, thereby modifying the physicochemical surface properties of oxidized implants: ) J DD D D properties. A study showed improved percentage BIC • The optimal oxide thickness of a porous surface ( values for implants with ion-implanted surfaces in structure appeared to be in the range of 1,000 to comparison to Diamond like Carbon coating and 5,000 nm. machined controls. Furthermore, bone integration • An optimum porosity of open pores is in the range appeared to be accelerated in the ion implantation of 19% to 30%, (i.e.) approximately 24%; with a Research 71 group . pore size of 2.0 μm. b) Optimum Roughness • Surface roughness values of 0.7 to 1.0 μm for Sa, 0.9 to 1.4 μm for Sq, and 27% to 46% for Sdr Medical The topography of rough surfaces is characterized by different surface roughness parameters (Ra, seemed to be optimum. • TiO2 in a crystalline phase seemed to be Rq, Rt, Rsk, Rku, ∆q, or λq, in 3D or 3D mode). optimal73. Hansson described that an average surface roughness Ra (filtering 50x50 µm) of about 1.5 µm gave the d) Controversies With Respect To Implant strongest fixation for a bone-metal interface. If the Topographies implants are smoother or rougher than this, the Machined titanium surfaces have been reported Global Journal of anchorage between bone and implant decreases. to favor fibroblastic growth, migration, and spread, and A typical measure of implant surface roughness therefore were considered favorable for formation of is the Ra value: the arithmetic mean value of the surface peri-implant soft tissue. On the other hand, because of departures from the mean plane. Unfortunately, surfaces the increased proliferative activity of fibroblasts on may have very different morphologies and still share a machined surfaces, fibrous capsules or connective common Ra value. It is clear that height descriptors tissue overgrowth can form, compromising local blood alone do not adequately describe surface roughness. supply and leading to failure of the implant to integrate More recently, the average peak spacing (Sa) has been with the soft tissue. To overcome this problem, rough associated with implant behavior. There is enough titanium surfaces have been suggested in several evidence for the positive relationship between surface studies.

Rough titanium surfaces have been reported to These nanometer structures may also give the improve attachment and decrease growth and spread of cells positive guidance by means of the selective fibroblasts. However, a diminished growth of fibroblasts attachment of osteoblasts to the implant surface. This on rough titanium surfaces can result in the formation of selective attachment process might result in the a thin connective tissue that will not be capable of improvement of initial healing around dental implants22. supporting surrounding tissue structures. In addition, rough implant surfaces have been reported to be f) Re-Osseo integration especially prone to peri-implant infection and seem also Persson et al (2001) evaluated reosseoin-

to attract inflammatory cells. tegration of SLA (Sandblasted and acid etched) and Another suggested titanium surface comprises turned implants in dogs. They found that reosseoin- grooved topography, which has been demonstrated to tegration was substantial for implants with SLA surfaces favor the orientation and alignment of fibroblasts and but only minimal for exposed smooth (turned) surfaces. claimed in several studies to be appropriate for the Reosseointegration (BIC) at SLA surfaces averaged 84% 77 2014 establishment of an organized connective tissue compared to 22% at turned implant surfaces . structure around the implant. However, the exact

Year IX. Recent Innovations and Future topographic configurations of grooved titanium surfaces Directions 46 that are appropriate for the in vivo establishment of long- term stable and overall optimal peri-implant soft tissue a) Nanotechnology conditions are still largely unknown. Nanotechnology is the engineering of functional There is a lack of knowledge about the ideal syste ms at the molecular scale. Materials reduced to the implant surface characteristics that lead to the nanoscale can show different properties compared to establishment of optimal connective tissue and what they exhibit on a macro scale, enabling unique attachment around titanium implants. The acid-etching applications. For instance, opaque substances become and blasting methods generally do not change the main transparent (copper); stable materials turn combustible compositional surface elements of the titanium, which (aluminum); insoluble materials become soluble (gold). consist mainly of titanium and oxygen, but rather the A material such as gold, which is chemically inert at surface morphology/topography and consequently normal scales, can serve as a potent chemical catalyst surface roughness, two action mechanisms of at nanoscale. Much of the fascination with nanotech- osseointegration of oxidized implants have been nology stems from these quantum and surface proposed: phenomena that matter exhibits at the nanoscale. Volume XIV Issue IV Version I 1) mechanical interlocking through bone growth in Nanotechnology involves materials that have a

J pores and nano-sized topography or are composed of nano -sized () 2) biochemical bonding74-75. materials. These materials have a size range between 1

e) Surface roughness at the nano scale level and 100 nm (109m) Nanotechnology often involves one-

The chemistry and roughness of implant dimensional concepts (nano-dots and nano wires) or surfaces play a major role in the biological events that the self-assembly of more complex structures Research follow implantation. Nevertheless, surfaces are often (nanotubes). Materials are also classified according to developed using an empirical approach with in vitro and their form and structure as nanostructures, nanocrystals, nano coatings.

Medical in vivo tests. Most of the surfaces currently available have random topography with a wide range of b) Methods of Creating Nano-topography thicknesses, from nanometers to millimeters76. Nanotechnology requires novel ways of The exact biological role of these features is manipulating matter in the atomic scale. Several unknown because of the absence of standardized approaches are currently prevalent in the experimental surfaces with repetitive topography at the nano-sized application to endosseous implants. level (e.g. pits with fixed diameters and depth, lanes with 1. One approach involves the physical method of controlled profiles). Such controlled or standardized Global Journal of compaction of nano-particles of TiO2 vs. micron- surfaces might help to understand the interactions level particles to yield surfaces with nano scale between specific proteins and cells. These standardized grain boundaries78. An advantage of this method surfaces might also promote early bone apposition on is that it conserves the chemistry of the surface the implants. among different topographies. Only a few studies have reported modifications 2. Second is the process of molecular self- to the roughness as well as the chemistry at the assembly. Self-assembled monolayers (SAMs) nanometer scale in a reproducible manner. Most of are formed by the spontaneous chemisorptions these attempts have used processing methods from the and vertical close-packed positioning of electronic industry such lithography and surface laser- molecules onto some specific substrata, exposing pitting. only the end-chain group(s) at the interface . The

exposed functional end group could be an osteo implant biomechanical interlock. Four interrelated inductive or cell adhesive molecule. An example properties of an implant surface affect osteogenic of this is the use of cell adhesive peptide domains activity: chemical composition, surface energy, surface (RGD domains) appended to SAMs composed of roughness, and surface morphology.Osseointegration poly ethylene glycol (PEG) and applied to the and its underlying mechanisms of cell attachment, titanium implant surfaces. migration, proliferation, and differentiation are sensitive 3. A third method is the chemical treatment of to one or more of these properties. Methods of different surfaces to expose reactive groups on enhancing the implant surface include alteration of the the material surface and create nano-scale microstructure and modification of its physiochemical topography. This is popular among current dental parameters, including surface free energy and implant investigators. NaOH treatment catalyzes wettability. the production of titanium nanostructures outward The surface qualities are of utmost importance from the titanium surface79. in establishing of a reaction between the implant and the

4. The deposition of nanoparticles on to the titanium tissues. This concerns the surface structure as well as 2014 surface represents a fourth approach to imparting its chemical and biological properties. Much attention nanofeatures to a titanium dental implant80 Sol– has been focused on the importance of the Year gel transformation techniques achieve deposition macrostructure of the implants for establishing retention 47 of nano meter-scale calcium phosphate in the bone. More attention will probably be focused in accretions to the implant surface81-82. Alumina, the future on the biological effects of the surface Titania, zirconia and other materials can also be structure on the microstructural and ultrastructural levels applied83. Owing to their resultant atomic-scale as well as on the surface chemistry of the implants. interactions, the accretions display strong Progress in these fields based on knowledge of the physical interactions. biological effects may provide implants with improved a. In a modified approach, Nishimura and tissue response and clinical performance in the future. colleagues [2007] demonstrated a directed approach to assembly of CaPO4 nano features on References Références Referencias dual acid-etched cp Titanium implant surfaces. The deposition of discrete 20–40nm nano- 1. Glossary of Periodontal Terms.4th ed. American particles on an acid-etched titanium surface led to Academy of Periodontology.Chicago,

increased mechanical interlocking with bone and Illinois;2001.Implant,oral; p.27. the early healing of bone at the endosseous 2. Jan Eirik Ellingsen. Surface configurations of dental Volume XIV Issue IV Version I implants. Periodontology 2000 1998; 17: 36-46. ) J DD D implant surface in a rat model. One of the main D

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related debris84. Inorganic Surface Modifications for Titanium Implant

5. A fifth approach to creating nano scale Surfaces. Pharmaceutical Research 2008;25Vol. 25, No. 10, October 2008 DOI: 10.1007/s11095-008- topography on Titanium is the use of optical Research methods (typically lithography) reliant on wave 9617-0. length specific dimensions to achieve the 4. Brunette DM. Fibroblasts on micromachined

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require considerable development prior to clinical 5. Clark P, Connolly P, Curtis AS, Dow JA, Wilkinson translation. The present use of lasers to promote CD. Topographical control of cell behaviour. I. micron-level groove on an implant surface can Simple step cues. Development. 1987; 99(3):439-

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MF. The early remodeling phases around titanium expression in a rat implant model. Bone 2005; 36 : Global Journal of implants: a histomorphometric assessment of bone 931– 940. quality in a 3- and 6-month study in sheep. Int J Oral 57. Park JM, Koak JY, Jang JH, Han CH, Kim SK, Heo Maxillofac Implants. 1999 Mar-Apr; 14(2):189-96. SJ. Osseointegration of anodized titanium implants 45. de Jonge LT, Leeuwenburgh SC, Wolke JG, Jansen co ated with fibroblast growth factor-fibronectin JA. Organic-inorganic surface modific-ations for (FGF-FN) fusion protein. Int J Oral Maxillofac titanium implant surfaces. Pharm Res. 2008 Implants. 2006 Nov-Dec;21(6):859-66. Oct;25(10):2357-69. 58. S. Munisamy; T. K. Vaidyanathan; J. Vaidyanathan. 46. Yamazaki Y, Oida S, Ishihara K, Nakabayashi N. A Bone-Like Precoating Strategy For Implants: Ectopic induction of cartilage and bone by bovine Collagen Immobilization And Its Mineralization On

Pure Titanium Implant Surface. Journal of Oral Non -Submerged Titanium Implants With a Implantology 2008 ; 34:67-75 Chemically Modified Sandblasted and Acid-Etched 59. Lifland MI, Kim DK, Okazaki K. Mechanical Surface: 3-Year Results of a Prospective Study in properties of a Ti-6A1- 4Vdental implant produced by the Posterior Mandible. J Periodontol 2010;81:809- electro-discharge compaction. Clin Mater 1993; 818. 14:13-9. 71. Miguel A. De Maeztu, Inigo Braceras Meng ,J. Inaki 60. Drummond JF, Dominici JT, Sammon PJ, Okazaki Alava, M. Angeles Sanchez-Garces, Cosme Gay- K, Geissler R, Lifland M I, et al. A light and scanning Escoda. Histomorphometric Study of Ion electron microscopic evaluation of electro- Implantation and Diamond-like Carbon as Dental discharge-compacted porous titanium implants in Implant Surface Treatments in Beagle Dogs. Int J rabbit tibia. J Oral Implantol 1995; 21:295-303. Oral Maxillofac Implants 2007; 22:273-279. 61. Story BJ, Wagner WR, Gaisser DM, Cook SD, Rust - 72. M.M. Shalabi, A. Gortemaker, M.A. Van’t Hof, J.A. Dawicki AM. In vivo performance of a modified CS Ti Jansen, and N.H.J. Creugers.Implant Surface

2014 dental implant coating. Int J Oral Maxillofac Implants Roughness and Bone Healing: a Systematic Review 1998; 13:749-57. J Dent Res.2006;85(6):496-500. Year 62. Richard J. LoTzara,Tiziano Testorf, Paolo Trisi, 73. Young-Taeg Sul, Carina Johansson, Ann 50 Stephan S, Porter, Roberto L. Weinstein. A Human Wennerberg, Lee-Ra Cho, Beom-Seok Chang, Histologie Anaiysis of Osseotite and Machined Tomas Albrektsson, Optimum Surface Properties of Surfaces Using impiants with 2 Opposing Surfaces. Oxidized Implants for Reinforcement of Int J Periodontics Restorative Dent 1999;19:117- Osseointegration: Surface Chemistry, Oxide Thic- 129. kness, Porosity, Roughness, and Crystal Struc-ture. 63. Aparicio C, Gil FJ, Fonseca C, Barbosa M, Planell Int J Oral Maxillofac Implants 2005;20:349-359. JA. Corrosion behavior of commercially pure 74. Sul YT, Johansson C, Byon E, Albrektsson T. The titanium shot blasted with different materials and bone response of oxidized bioactive and non- size of shot particles for dental implant applications. bioactive titanium implants. Biomaterials. 2005 Biomaterials2003; 24:263-73. Nov;26(33):6720-30. 64. Massaro C, Rotolo F, De Riccardis F, Milella E, 75. Wael Att, Masahiro Yamada, Takahiro Ogawa, Effect Napoli A, Wieland M. Comparative investigation of of Titanium Surface Characteristics on the Behavior the surface of commercial titanium dental implants. and Function of Oral Fibroblasts Int J Oral Maxillofac Part 1: chemical composition. J Mater Sci Mater Implants 2009;24:419-431. Volume XIV Issue IV Version I Med 2002; 13:535-48. 76. Anselme K, Bigerelle M, Noel B, Lost A, Hardouin P.

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Global Journal of 68. D. Buser, N. Broggini, M. Wieland, R.K. Schenk, bioactive nano coatings for medical applications. A.J. Denzer, D.L. Cochran et al. Enhanced Bone Part 1: An Introduction. Nano med 2006; 1:311-9. Apposition to a Chemically Modified SLA Titanium 81. Liu D M, Troczynski T, Tseng W J. Water-based sol- Surface. J Dent Res. 83(7):529-533,2004. gel synthesis of hydroxy-apatite: process 69. D. Buser, N. Broggini, M. Wieland, R.K. Schenk, development. Biomaterials 2001; 22:1721-30. A.J. Denzer, D.L. Cochran, B. Hoffmann et al. 82. Kim H M, Kokubo T, Fujibayashi S, Nishiguchi S, Enhanced Bone Apposition to a Chemically Nakamura T. Bioactive macro porous titanium Modified SLA Titanium Surface J Dent Res 2004; surface layer on titanium substrate. J Biomed Mater 83(7):529-533. Res 2000; 5(52):553-7. 70. Michael M. Bornstein, Julia-Gabriela Wittneben, Urs Brägger, Daniel Buser. Early Loading at 21 Days of

83. Lee S H, Kim H W, Lee E J, LiL H, Kim H E. Hydroxyapatite–TiO2 hybrid coating on Ti implants. J Biomater Appl 2006; 20:195-208. 84. Nishimura I, Huang Y, Butz F, Ogawa T, Lin L, Jake Wang C. Discrete deposition of hydroxyl -apatite nano particles on titanium implant with predisposing substrate micro topography accelerated osseointegration. Nanotechnology 2007; 18: 245101 (9pp). 85. Coelho PG, Suzuki M. Evaluation of an IBAD TH in- film process as an alternative method for surface in corporation of bioceramics on dental implants. A study in dogs .J Appl Oral Sci 2005; 13:87-92.

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This page is intentionally left blank Volume XIV Issue IV Version I J () Research Medical Global Journal of

Effect of Probe-Tip Placement on Impedance Audiometry

By Sunita Gudwani, Sanjay Kumar Munjal & Naresh K. Panda

Post Graduate Institute of Medical Educational and Research, India

Abstract- Introduction: Impedance audiometry measures intactness of middle ear system and acoustic arc. It has become an essential tool in audiological practice, any variability leads to erroneous diagnosis. The most likely error to occur is by different probe-tip placements in the ear canal. The present study was conducted to verify this hypothesis. Subjects, Material and Methods: The study was conducted on twenty normal hearing subjects (40 ears) with age range of 17 to 28 years. It included measurements of compliance, ear canal volume, middle ear pressure and acoustic reflexes. These parameters were studied for two probe-tip positions (i) ≤1mm; and (ii) 2mm inside the ear canal. Results: Significant differences were observed between the two probe-tip positions for ear canal volume. During acoustic reflex for 2000 Hz probe-tone, the change in compliance was significantly affected. Keywords: probe-tip, placement, tympanometry, acou-stic reflex. GJMR-J Classification: NLMC Code: WZ 112.5.O8

EffectofProbe-TipPlacementonImpedanceAudiometry

Strictly as per the compliance and regulations of:

© 2014. Sunita Gudwani, Sanjay Kumar Munjal & Naresh K. Panda. This is a research/review paper, distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License http:// creativecommons. org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Effect of Probe-Tip Placement on Impedance Audiometry

Sunita Gudwani ρ, Sanjay Kumar Munjal α & Naresh K. Panda σ

Abstract- Introduction: Impedance audiometry measures each ear canal (cited in Feldmann, 1970). The term intactness of middle ear system and acoustic arc. It has impedance was first introduced as an electrical term by become an essential tool in audiological practice, any Heaviside in 1886 (cited in Heaviside, 1892). Webster variability leads to erroneous diagnosis. The most likely error extended the principles of electrical impedance laws to to occur is by different probe-tip placements in the ear canal.

the analysis of acoustical system (Webster, 1919). The 2014 The present study was conducted to verify this hypothesis. first acoustic impedance measures made with an actual Subjects, Material and Methods: The study was conducted on probe tube inserted into the human ear canal were Year twenty normal hearing subjects (40 ears) with age range of 17 reported by Troger in 1930 (cited in Metz, 1946). Martin to 28 years. It included measurements of compliance, ear 53 canal volume, middle ear pressure and acoustic reflexes. in 1971 reported the first survey of audiologic practices These parameters were studied for two probe-tip positions (i) where tympanometry or acoustic immittance measures ≤1mm; and (ii) 2mm inside the ear canal. were not mentioned among the procedures used by Results: Significant differences were observed between the practicing audiologists. The recent survey of practicing two probe-tip positions for ear canal volume. During acoustic audiologists reported by Martin et al in 1998 indicated reflex for 2000 Hz probe-tone, the change in compliance was that 96% of the respondents routinely used acoustic significantly affected. immittance measures in their daily practice. Acoustic Conclusions: The results can be explained by ear canal immittance instruments and procedures are now resonance principles. Thus, the study verifies that the commonplace in audiology, otolaryngology, pediatric placement of probe-tip affects the measurements of and other diagnostic clinics. The most recent guidelines tympanometry and acoustic reflex testing. for screening middle ear function recommended by Aim and Objectives: To study the changes of tympanometric ASHA (1997) are based on the use of acoustic and acoustic reflex test measures with different placements of immittance measures. When it has become such an probe-tip. important tool for our clinical settings, then awareness of Volume XIV Issue IV Version I

Keywords: probe-tip, placement, tympanometry, acou- the variability in measurements becomes an essentiality ) J DD D D

stic reflex.

for an audiologist. The error most likely to happen is by ( different placements of probe-tip in the ear canal I. Introduction leading to variability. To verify this hypothesis the nergy transfer in the human ear is initiated when present study was conducted. sound waves are presented to the ear canal and The hypothesis proposed was based on the E sound pressure is applied to the tympanic principle that accurate determination of the static Research membrane. Energy begins to flow and tympanic compliance depends on an accurate estimation of the membrane vibrates with a characteristic amplitude and ear canal volume. If ear canal volumes are Medical phase that depends upon the acoustic admittance of overestimated, then the static compliance will be the entire system (Zwislocki, 1963). The transfer of underestimated that could lead to suspicion of middle energy from the ear canal to the middle ear and ear effusion where none exists. Secondly, in the case of ultimately to the cochlea can be described from flat tympanogram, the estimation of equivalent volume measures of sound pressure level (SPL) at the lateral can provide a clue to the cause of the flat tympanogram, Stoppenbach, 2002). whether it is due to artifact, tympanic membrane surface of the tympanic membrane (Wiley and perforation or patent tympanostomy tube, or middle ear Global Journal of Lucae (1867) was the first to measure tympanic effusion (Fowler CG & Shanks JE, 2002). membrane and middle ear characteristics in humans using an instrument called the interference otoscope, by II. Material and Methods presenting sound into both ears of a participant and The study included twenty adult normal hearing listening to the level of sound reflected in subjects of either sex with age range of 17 to 28 years. Subjects’ selection criteria were normal hearing, with no

external and middle ear pathology on clinical Author : Department of Otolaryngology, Head and Neck Surgery, ρ α σ examination. The impedance audiometry was carried Post Graduate Institute of Medical Educational and Research,

Chandigarh, India. e-mails: [email protected], out in sound-treated rooms of Speech and Hearing Unit [email protected], [email protected] of ENT OPD, PGIMER, Chandigarh. The equipment

used for impedance audiometry was SD 30 The study was conducted in the Speech and tympanometer. The 226 Hz probe-tone was used for Hearing Unit, Department of Otorhinolaryngology, tympanometric measurements. The pressure in the PGIMER, Chandigarh. The investigations were carried external auditory canal was varied from +200 to -300 out complying the ethics and were approved by the daPa at the rate of 200 daPa per second. The ethical committee of the institute. Each of the subjects parameters noted were compliance, ear canal volume was told about the purpose of the investigation and (or base volume) and middle ear pressure. The acoustic written informed consent was taken from the patients. reflex testing was also conducted. The change in compliance denoted the acoustic reflex in the monitored III. Observations and Results ear with probe tip. The reflexes were elicited and A total of twenty subjects with normal hearing recorded at 500 Hz, 1000 Hz, 2000 Hz and 4000 Hz at and healthy external & middle ear were included in the 90 dB HL. The change in compliance was also noted study. The subjects with age range 17 to 28 years of from 80 dB HL to 100 dB HL at 1000 Hz. All these either sex were assessed for tympanometry and

2014 parameters were studied in two placement positions of acoustic reflex test in both the ears. Thus total number the probe-tip (i) ≤1mm; and (ii) 2mm inside the ear of ears assessed was forty (40 ears). The table 1 shows Year canal to understand the variability. that highly significant differences were observed 54 The data was subjected to appropriate between two positions of the probe-tip for ear canal statistical measures. The values of mean for central volume. Differences were also observed for middle ear tendency and standard deviation for variability were pressure in two positions but could not reach the computed. Paired t-test was administered for statistical significance level. Similar results were seen for comparison of two positions of probe-tip in the ear compliance differences. canal. The significance tests were two-tailed and conducted at or above the 5% significance level. Gudwani, Effect of probe-tip placement on impedance audiometry Table 1 : Findings of tympanometry (N= 40) st nd 1 position (≤1mm) 2 position (2mm) ‘t’ Parameters Mean SD Mean SD Compliance(cc.) 0.788 0.427 0.778 0.480 0.639

Volume XIV Issue IV Version I E C Vol.(cc.) 1.443 0.398 1.147 0.307 5.989***

J ME Press. (daPa) -8.13 20.50 -6.25 16.28 1.292 () *p<0.05; **p<0.01; ***p<0.001. Table 1 depicts mean, standard deviation (SD) and ‘t’-value of compliance, ear canal volume (E C Vol.) and

middle ear pressure (ME Press.). Gudwani, Effect of probe-tip placement on impedance audiometry Research Table 2 : Findings of Acoustic Reflex Test (N= 40) d 1st 2nd Medical position position t’ (≤1mm) (2mm) Frequency Mean SD Mean SD 500 Hz -6.825 9. 142 -6.15 6.100 0.514 1000Hz -8.975 8.368 -9.400 4.986 0.354 2000Hz -2.400 3.350 -5.250 9.190 2.119* 4000Hz -1.350 2.887 -2.250 4.490 1.630 Global Journal of *p<0.05; **p<0.01; ***p<0.001. Table 2 shows mean, standard deviation (SD) s ignificance. For 500 Hz and 1000 Hz probe and ‘t’-value of ‘change in compliance’ during acoustic frequencies, the compliance shift with acoustic reflex

reflex at 90dB SPL for different frequencies tested. was again not significantly different in two probe-tip As seen from the table 2 statistically significant positions. difference was found between two positions of the probe-tip at 2000 Hz. It means that change in IV. Discussion compliance during acoustic reflex for 2000 Hz probe - Tympanometry is a measure of the acoustic tone was affected by position of the probe-tip in the ear admittance or compliance in the ear canal as a function canal. Differences were observed for 4000 Hz probe of changing ear canal pressure (Wiley TL and frequency but could not reach the statistical Stoppenbach DT, 2002). Tympanometric measures

© 2014 Global Journals Inc. (US) Effect of Probe-Tip Placement on Impedance Audiometry include contributions offered by the volume of air sound. Secondly modification in length of ear canal also between the probe-tip and the tympanic membrane as affects the resonant frequency. As explained by Goode well as the entire middle ear system. The obtained RL et al, 1977 that lengthening the canal lowers the measures will vary with individual ear canal resonant frequency and decreasing the length raises the characteristics (e.g. shape and volume) (Wiley TL and frequency. In such situation the placement of the probe- Stoppenbach DT, 2002). The probe -tip position thus tip would either underestimate or overestimate the SPL determines the volume of air in the external ear canal. If measured. It would also affect the change in compliance the placement of probe-tip is deep in the ear canal the during acoustic reflex. volume would be less and with lateralized placement V. onclusions volume of the ear canal would be greater. Similar C findings were found in the present study that when the The present study based on data of 40 ears, placement of probe-tip was ≤1mm the ear canal volume shows that placement of probe-tip affects the was large and with placement position of probe-tip 2mm measurements of tympanometry and acoustic reflex 2014 deep the ear canal volume was smaller. To overcome testing to some extent. The change of compliance these differences the compensated measures were

during acoustic reflex is the most affected parameter by Year recommended by ANSI (ANSI S3.39-1987) that shift of probe-tip position during impedance audiometry. eliminates the contribution of the ear canal to the overall 55 acoustic admittance or compliance (ASHA, 1990). The VI. Ackn owledgements ear canal volume is not the direct measure but it is the We are thankful to the Academic Committee estimate of the admittance or compliance offered by the and Ethical Committee of PGIMER, Chandigarh, for volume of air between the probe-tip and the tympanic support and justification of the study. membrane. The measure is based on the principle that under specified conditions, a given volume of air has a References Références Referencias specified admittance or compliance (Shanks & Lilly, 1981). 1. American National Standards Institute, 1987. The differences of compliance in two positions Specifications for instruments to measure aural were not found statistically significant. The probable acoustic impedance and admittance (aural acoustic reason for this might be the instrument used (Siemens immittance). ANSI S3.39-1987. New York: American SD 30) where the compliance measured with 226 Hz Institute of Physics. probe-tone at 200 daPa serves as an approximation of 2. American Speech-Language-Hearing Association, the compensated acoustic admittance of the ear canal. 1990. Guidelines for screening for hearing Volume XIV Issue IV Version I ) J

impairment and middle ear disorders. ASHA; DD D Similarly there were no significant differences D observed for middle ear pressure in two probe-tip 32(Suppl 2): 17-24. ( positions. Middle ear pressure is an indirect estimate 3. American Speech-Language-Hearing Association, made from the tympanometric peak pressure (TPP) 1997. Guidelines for audiologic screening. Rockville (Wiley TL and Stoppenbach DT 2002), and ANSI defined MD: American Speech-Language-Hearing Assoc-

TPP as the pressure in deca-Pascals at which the peak iation. Research of the tympanogram occurs (ANSI S3.39-1987). As the 4. Feldmann H, 1970. A history of audiology. Transl subject included in the study were with normal middle Beltone Inst Hear Res; 22. ear on examination, thus the middle ear pressure 5. Fowler CG, Shanks JE, 2002. Tympanometry. In: Medical measured should be normal showing non-significant Katz J, Burkard RF, Medwetsky L (eds) Handbook th differences in two positions of the probe-tip. of clinical audiology 5 edi. Philadelphia: Lippincott Significant differences were obtained for Williams & Wilkins; pp 175-204. change of compliance in acoustic reflex testing at 2000 6. Goode RL, Friedrichs R, Falk S, 1977. The effects of Hz frequency but the differences observed at 4000 Hz surgical modification of the external ear on hearing could not reach statistical significance. These results thresholds. Ann Otol Rhinol Laryngol; 86: 441-450. can be explained by ear canal resonance principles. The 7. Goode RL, 2001. Auditory physiology of the external Global Journal of resonant frequency is based on the tube length and is ear. In: Jahn AF & Sacchi JS (eds) Physiology of the nd assumed independent of diameter in the normal ear ear 2 edi. San Diego: Singular Thomson Learning; (Goode RL, 2001). The resonant frequency is calculated pp 147-159. by the formula F0 = 1/4th wavelength of sound (∂) 8. Heaviside O, 1892. Electrical papers (Vol. I and II). multiplied with ear canal length. In a normal average ear London: MacMillan. canal the resonant frequency is about 3500 Hz (= 10cm 9. Lilly DJ, Shanks JE, 1981. Acoustic immittance of an wavelength) (Goode RL, 2001). In tympanometry the enclosed volume of air. In: Popelka CR, (edr) probe-tone used is 226 Hz with longer wavelength Hearing assessment with the acoustic reflex. New hence the F0 would be occurring at ¼th wavelength of York: Grune & Stratton, pp. 145-160.

10. Martin CD, Pennington CD, 1971. Current trends in audiometric practices. ASHA; 13: 671 -677. 11. Martin CD, Champlin CA, Chambers JA, 1998. Seventh survey of audiometric practices in the United States. J Am Acad Audiol; 9: 95 -104. 12. Metz O, 1946. The acoustic impedance measured on normal and pathological ears. Acta Otolaryngol; (Suppl 63): 1-245. 13. Webster AG, 1919. Acoustical impedance and the theory of horns and of the phonographs . Proc Natl Acad Sci USA; 5: 275-282. 14. Wiley TL, Stoppenbach DT, 2002. Basic principles of acoustic immittance measures. In: Katz J, Burkard

2014 RF, Medwetsky L (editors) Handbook of clinical audiology 5 th edi. Philadelphia: Lippincott Williams Year & Wilkins, pp. 159-174. 56 15. Zwislocki J, 1963. An acoustic method for clinical examination of the ear. J Speech Hear Res; 6: 303- 314.

Volume XIV Issue IV Version I

J () Research Medical Global Journal of

A Method to Construct an Interim Obturator using Presurgical Tissues for Maxillary Palatal Defect By Sumeet Sharma, Harvinder Singh, Sarbjeet Singh & Nikhil Dev wazir Institute of Dental Sciences, India Abstract- The presence of oral cancer necessitates the surgical removal of all or part of the maxilla, leaving the patient with a defect that compromises the integrity and function of the oral cavity. Surgical unit along with the prosthodontic counterpart goes hand in hand for the fulfilment of the post restorative re-establishment of the oral functioning. The immediate line of treatment includes maxillectomy with the initial insertion of an immediate surgical obturator at the time of surgery followed by the insertion of interim obturator for initial healing which thereafter replaced by definite prosthesis once the tissues are stabilised. This article will provide a method of fabricating an interim obturator which will be very easy, less time consuming, inexpensive and comfortable for the patient. Material used for this type of obturator is the common self cure acrylic resin duplicating the lost tissues using the preoperative cast. GJMR-J Classification: NLMC Code: WU 600

A MethodtoConstructanInterimObturatorusingPresurgicalTissuesforMaxillaryPalatalDefect

Strictly as per the compliance and regulations of:

© 2014. Sumeet Sharma, Harvinder Singh, Sarbjeet Singh & Nikhil Dev wazir. This is a research/review paper, distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License http:// creativecommons. org/licenses/by- nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

A Method to Construct an Interim Obturator using Presurgical Tissues for Maxillary Palatal Defect

Sumeet Sharma α, Harvinder Singh σ, Sarbjeet Singh ρ & Nikhil Dev wazir Ѡ

Abstract- The presence of oral cancer necessitates the replacement of the teeth and palate aids in speech, surgical removal of all or part of the maxilla, leaving the patient mastication, esthetics and morale7-8. However, the with a defect that compromises the integrity and function of prosthodontist should not rush to provide artificial for the 2014 the oral cavity. Surgical unit along with the prosthodontic interim obturator prosthesis. The friability of tissue after counterpart goes hand in hand for the fulfilment of the post radiation therapy, if it has been used, usually allows use Year restorative re-establishment of the oral functioning. 7 The immediate line of treatment includes of only the simplest type of prosthesis . Also posterior 57 maxillectomy with the initial insertion of an immediate surgical teeth should not be added to interim obturator pros- obturator at the time of surgery followed by the insertion of thesis since they may impose excessive stress on the interim obturator for initial healing which thereafter replaced by wound and delay the healing process7. definite prosthesis once the tissues are stabilised. Numerous methods of polymerization and This article will provide a method of fabricating an processing are now available and attracted the attention interim obturator which will be very easy, less time consuming, of several investigators9-10. Takamata and Setcos9 inexpensive and comfortable for the patient. Material used for reviewed the various modifications of denture base this type of obturator is the common self cure acrylic resin resins and evaluated pourable resin, microwave- duplicating the lost tissues using the preoperative cast. polymerized resin, and light activated resins. They found I. Introduction that conventional techniques with heat-activated resins are not only more time consuming, but also may provide axillary cancer surgery often creates a defect reduced accuracy. Takamata et al11 compared the that may affect speech, swallowing, masti- adaptation of denture base materials processed on a cation, and facial appearance. Prosthetic master cast. The greatest discrepancy in adaptation to Volume XIV Issue IV Version I

M ) rehabilitation after total maxillectomy has historically J DD D the master cast occurred with the heat activated resin D 1 involved the use of maxillary obturator prosthesis . than self activated resin while the microwave-processed ( Resection of the hard palate establishes communication resin provided the best adaptation. between the oral and nasal cavities and often the This article describes an easy method to make 2 maxillary sinus . interim obturator prosthesis more comfortable during the A maxillary obturator prosthesis can re-establish time required for postsurgical healing. The time saved Research 3-4 physical separation of the oral cavities .obturator and ease of the procedure, in addition to the use of constructed for maxillectomy patients are grouped duplicated artificial teeth, make this technique more according to their stage of use. The surgical obturator is economical than the flasking method using heat Medical fabricated prior to surgery; the interim obturator polymerized acrylic resin and light activated resin. It also prosthesis is constructed removal of the surgical obt - provide improved fit and a smoother surface than urator and packing, while the definitive obturator achieved by other techniques, such as making a matrix prosthesis is provided for the patient 6 to 12 month after with irreversible hydrocolloids and using the pre-existing 3-4 surgery . tissue for duplication before surgery12. Interim obturator prosthesis is normally placed after 7 to 10 days after surgery5-6. As healing II. Technique Global Journal of progresses, interim obturator prosthesis is fabricated 1. A presurgical cast is made using a type II dental and extended further into the defect, with subsequent plaster with the water: powder ratio of 0.50 as additions to improve the seal and retention7. Artificial recommended and a final cast is made after Author α : Department of Prosthodontics, Institute of dental sciences, maxillectomy using dental stone IV(Denflo extra Sehora. e-mail: [email protected] hard die stone;prevest DenPro®,India) with water: Author σ : Department of Prosthodontics, Institute of dental sciences, powder ratio of 0.24 as recommended.(Fig.1 and

Sehora. Fig. 2) Author ρ : Department of Oral Medicine and Radiology, Institute of Dental Sciences, Sehora. Author Ѡ : Department of Conservative and Endodontics, Institute of Dental Sciences, Sehora.

7. Once the teeth and the shellac base plate wax is secured on the presurgical cast, a putty impression material (Affinis; Coltene Whaledent, Cayahoga, Ohio) is then adapted over the cast which includes all the arranged acrylic teeth, the palatal area, remaining natural teeth and the anterior sulcus. 8. A stainless steel hollow cylindrical mould with the dimension of 25mm length and 10mm width is then Figure 1 : Presurgical maxillary cast inserted on the palatal portion on the adapted putty

Figure 2 : Postsurgical Maxillary cast impression material which will facilitate the ingress 2. On the presurgical cast, prefabricated acrylic teeth of the acrylic resin. (Fig.6) (Rolex cross linked acrylic teeth, India) are arranged if there is any edentulous area exists.(Fig.3). 2014

Year

Figure 6 : Stainless steel mould inserted in palatal

portion

Figure 3 : Arranged acrylic teeth in edentulous areas 9. Remove the putty matrix from the presurgical cast.

3. On the presurgical cast, remove one by one the Arrange the acrylic resin teeth in the respective teeth which in later stage is planned to be extracted indentation made in the putty matrix. during the maxillectomy procedure. 10. Secure the acrylic teeth with the matrix using a 4. Arrange prefabricated acrylic teeth on the cyanoacrylate. (Fig.7) edentulous area duly created by removal of anterior teeth.(Fig.4)

Volume XIV Issue IV Version I J ()

Figure 7 : Acrylic teeth secured in place

Research 11. Adapt Co-Cr wire (Sun- Cobalt Clasp wire; Dentsply, Figure 4 : Acrylic teeth placed following removal of Tochigi, Japan) clasps to the teeth on the natural teeth postsurgical cast to retain and stabilize the Medical 5. Adapt a shellac base plate wax (Hiflex shellac base prosthesis and secure the tags of the clasp using plate; Prevest DenPro®,India) with the margin cyanoacrylate and coat the cast by painting

extended till the interproximal gingival level of separating medium with a brush.(Fig. 8) remaining natural teeth and flushing with the lingual cervical margins of the acrylic teeth. (Fig. 5) Global Journal of

Figure 8 : Clasps adapted Figure 5 : Shellac base plate adapted 12. Adapt the putty matrix on the postsurgical cast using the reference of natural teeth and the buccal 6. Seal the shellac base plate wax using sticky wax to tissues. prevent any dislodgement during impression 13. Secure the putty matrix periphery with the tissues making. using a sticky wax.(Fig. 9).

obturator prosthesis permits the immediate replacement of postoperative anterior teeth and maxillary palatal form. This method of fabrication not only reduces the time consumed during fabrication also helps in rehabilitation of patient undergoing maxillectomy in an expedious and non-traumatic manner. This kind of method is limited to a lesser extent of the tissue loss whereas; when the extent of the maxillectomy is deeper Figure 9 : Periphery secured and blocked with sticky a hollow bulb type of obturator is more preferable. wax 14. Pour a liquid mix of clear autopolymerizing resin References Références Referencias

(Palapress vario; Heraeus Kulzer Co) at a powder ; 1. Loh HS, Tan PH. Prosthetic management of liquid ratio of 10g to 7 ml through the stainless steel maxillofacial defects after surgery. Singapore Med J

mould attached to the matrix (Fig.10) 2014 1989; 30:74 – 78. 2. Johnson JT, Aramany Ma, Myers En: Palatal Year Neoplasm Reconstruction Considerations, Otolar- yngol Clin North Am 1983; 16:441 – 456. 59 3. Desjardins RP: Early Rehabilitative management of the maxillectomy patients. J Prosthet Dent 1977; 38:311 – 318. 4. Beumer J, Curtis TA, Eirtell DN: Maxillofacial Rehabilitation; Prosthetic and Surgical Conside-

Figure 10 : Clear autopolymerizing resin is poured rations. St. Louis, CV Mosby, 1989, pp 188 – 243.

through mould 5. Curtis TA, Beumer J III. Restoration of acquired hard 15. Place the cast with the resin during dough stage in palate defects; etiology, disability, and rehabilitation. a pressure pot with water. Heat the water gradually In: Beumer J, Curtis TA, Marunik MT, editors. from room temperature to 45 degrees celcius, at 2- Maxillofacial rehabilitation: prosthodontic and bar pressure for 30 mins12, to harden and reduce surgical considerations. St. Louis: Ishiyaku EuroAm- porosity of acrylic resin. erica; 1996.p. 225 – 84. 16. Once the resin is set, remove the putty matrix from 6. Kaplan P. Stabilization of an interim obturator the cast and evaluate the teeth and palatal portion prosthesis using a denture duplicator. J Prosthet Volume XIV Issue IV Version I

) J DD D duplicated in acrylic resin. Dent 1992; 67:337 – 9. D

17. Remove the prosthesis from the cast. Trim the 7. Kouyoumdjian JH, Chalian VA. An interim obturator ( excess acrylic resin with carbide bur (Laboratory prosthesis with duplicated teeth and palate. J Cardibe bur; Mani) and polish the prosthesis with Prosthet Dent 1984; 52; 560 – 2. finishing bur and waterproof abrasive paper 8. DaBreo EL, Chalian VA, Lingeman R, Reisbick MH.

conventionally.12 (Fig.11) Prosthetic and surgical management of osteogenic Research sarcoma of the maxilla. J Prosthet Dent 1990; 63:316 – 20. 9. Takamata T, Selcos JC; Resin denture bases: Medical Review of accuracy and methods of polymerization. Int J Prosthodont 1989; 2:555 – 562. 10. Alkhatib MB, Goodacre CJ, Swartz ML, Munoz CA,

Andres CL: Comparison of microvave – polymerized denture base resins. Int J Prosthodont 1990; 3:249 – Figure 11 : Finished Obturator 255.

Global Journal of III. Summary 11. Takamata T, Selcos JC; Phillips RW, Boone ME; Adaptation of acrylic resin denture as influenced by Effective obturation of the unilateral or bilateral the methods of polymerization. J Am Dent Assoc maxillectomy defect is a difficult task for the maxillofacial 1989; 119:271 – 276. prosthodontist. Multidisciplinary appr-oach to the 12. Mihoko Haraguchi, Hitoshi Mukohyama, Hishashi treatment is essential to achieve adequate retention and Taniguchi. J Prosthet Dent 2006; 95:469 – 72. function for the surgical obturator prosthesis. Duplication of the presurgical contours of the teeth and palatal tissue in interim obturator prosthesis may facilitate speech and deglutition and also improve estetics of the patient. This technique of making

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The individual Fellow and Associate designations accredited by Open Association of Research Society (US) credentials signify guarantees following achievements:

 The professional accredited with Fellow honor, is entitled to various benefits viz. name, fame, honor, regular flow of income, secured bright future, social status etc.

 In addition to above, if one is single author, then entitled to 40% discount on publishing research paper and can get 10%discount if one is co-author or main author among group of authors.  The Fellow can organize symposium/seminar/conference on behalf of Global Journals Incorporation (USA) and he/she can also attend the same organized by other institutes on behalf of Global Journals.  The Fellow can become member of Editorial Board Member after completing 3yrs.  The Fellow can earn 60% of sales proceeds from the sale of reference/review books/literature/publishing of research paper.  Fellow can also join as paid peer reviewer and earn 15% remuneration of author charges and can also get an opportunity to join as member of the Editorial Board of Global Journals Incorporation (USA)  • This individual has learned the basic methods of applying those concepts and techniques to common challenging situations. This individual has further demonstrated an in–depth understanding of the application of suitable techniques to a particular area of research practice. Note :

 In future, if the board feels the necessity to change any board member, the same can be done with ″ the consent of the chairperson along with anyone board member without our approval.

 In case, the chairperson needs to be replaced then consent of 2/3rd board members are required and they are also required to jointly pass the resolution copy of which should be sent to us. In such case, it will be compulsory to obtain our approval before replacement.

 In case of “Difference of Opinion [if any]” among the Board members, our decision will be final and binding to everyone.

″

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Process of submission of Research Paper

The Area or field of specialization may or may not be of any category as mentioned in ‘Scope of Journal’ menu of the GlobalJournals.org website. There are 37 Research Journal categorized with Six parental Journals GJCST, GJMR, GJRE, GJMBR, GJSFR, GJHSS. For Authors should prefer the mentioned categories. There are three widely used systems UDC, DDC and LCC. The details are available as ‘Knowledge Abstract’ at Home page. The major advantage of this coding is that, the research work will be exposed to and shared with all over the world as we are being abstracted and indexed worldwide.

The paper should be in proper format. The format can be downloaded from first page of ‘Author Guideline’ Menu. The Author is expected to follow the general rules as mentioned in this menu. The paper should be written in MS-Word Format (*.DOC,*.DOCX).

The Author can submit the paper either online or offline. The authors should prefer online submission.Online Submission: There are three ways to submit your paper:

(A) (I) First, register yourself using top right corner of Home page then Login. If you are already registered, then login using your username and password.

(II) Choose corresponding Journal.

(III) Click ‘Submit Manuscript’. Fill required information and Upload the paper.

(B) If you are using Internet Explorer, then Direct Submission through Homepage is also available.

Offline Submission: Author can send the typed form of paper by Post. However, online submission should be preferred.

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Preferred Author Guidelines

MANUSCRIPT STYLE INSTRUCTION (Must be strictly followed)

Page Size: 8.27" X 11'"

• Left Margin: 0.65 • Right Margin: 0.65 • Top Margin: 0.75 • Bottom Margin: 0.75 • Font type of all text should be Swis 721 Lt BT. • Paper Title should be of Font Size 24 with one Column section. • Author Name in Font Size of 11 with one column as of Title. • Abstract Font size of 9 Bold, “Abstract” word in Italic Bold. • Main Text: Font size 10 with justified two columns section • Two Column with Equal Column with of 3.38 and Gaping of .2 • First Character must be three lines Drop capped. • Paragraph before Spacing of 1 pt and After of 0 pt. • Line Spacing of 1 pt • Large Images must be in One Column • Numbering of First Main Headings (Heading 1) must be in Roman Letters, Capital Letter, and Font Size of 10. • Numbering of Second Main Headings (Heading 2) must be in Alphabets, Italic, and Font Size of 10.

You can use your own standard format also. Author Guidelines:

1. General,

2. Ethical Guidelines,

3. Submission of Manuscripts,

4. Manuscript’s Category,

5. Structure and Format of Manuscript,

6. After Acceptance.

1. GENERAL

Before submitting your research paper, one is advised to go through the details as mentioned in following heads. It will be beneficial, while peer reviewer justify your paper for publication.

Scope

The Global Journals Inc. (US) welcome the submission of original paper, review paper, survey article relevant to the all the streams of Philosophy and knowledge. The Global Journals Inc. (US) is parental platform for Global Journal of Computer Science and Technology, Researches in Engineering, Medical Research, Science Frontier Research, Human Social Science, Management, and Business organization. The choice of specific field can be done otherwise as following in Abstracting and Indexing Page on this Website. As the all Global

Journals Inc. (US) are being abstracted and indexed (in process) by most of the reputed organizations. Topics of only narrow interest will not be accepted unless they have wider potential or consequences.

2. ETHICAL GUIDELINES

Authors should follow the ethical guidelines as mentioned below for publication of research paper and research activities.

Papers are accepted on strict understanding that the material in whole or in part has not been, nor is being, considered for publication elsewhere. If the paper once accepted by Global Journals Inc. (US) and Editorial Board, will become the copyright of the Global Journals Inc. (US).

Authorship: The authors and coauthors should have active contribution to conception design, analysis and interpretation of findings. They should critically review the contents and drafting of the paper. All should approve the final version of the paper before submission

The Global Journals Inc. (US) follows the definition of authorship set up by the Global Academy of Research and Development. According to the Global Academy of R&D authorship, criteria must be based on:

1) Substantial contributions to conception and acquisition of data, analysis and interpretation of the findings.

2) Drafting the paper and revising it critically regarding important academic content.

3) Final approval of the version of the paper to be published.

All authors should have been credited according to their appropriate contribution in research activity and preparing paper. Contributors who do not match the criteria as authors may be mentioned under Acknowledgement.

Acknowledgements: Contributors to the research other than authors credited should be mentioned under acknowledgement. The specifications of the source of funding for the research if appropriate can be included. Suppliers of resources may be mentioned along with address.

Appeal of Decision: The Editorial Board’s decision on publication of the paper is final and cannot be appealed elsewhere.

Permissions: It is the author's responsibility to have prior permission if all or parts of earlier published illustrations are used in this paper.

Please mention proper reference and appropriate acknowledgements wherever expected.

If all or parts of previously published illustrations are used, permission must be taken from the copyright holder concerned. It is the author's responsibility to take these in writing.

Approval for reproduction/modification of any information (including figures and tables) published elsewhere must be obtained by the authors/copyright holders before submission of the manuscript. Contributors (Authors) are responsible for any copyright fee involved.

3. SUBMISSION OF MANUSCRIPTS

Manuscripts should be uploaded via this online submission page. The online submission is most efficient method for submission of papers, as it enables rapid distribution of manuscripts and consequently speeds up the review procedure. It also enables authors to know the status of their own manuscripts by emailing us. Complete instructions for submitting a paper is available below.

Manuscript submission is a systematic procedure and little preparation is required beyond having all parts of your manuscript in a given format and a computer with an Internet connection and a Web browser. Full help and instructions are provided on-screen. As an author, you will be prompted for login and manuscript details as Field of Paper and then to upload your manuscript file(s) according to the instructions.

To avoid postal delays, all transaction is preferred by e-mail. A finished manuscript submission is confirmed by e-mail immediately and your paper enters the editorial process with no postal delays. When a conclusion is made about the publication of your paper by our Editorial Board, revisions can be submitted online with the same procedure, with an occasion to view and respond to all comments.

Complete support for both authors and co-author is provided.

4. MANUSCRIPT’S CATEGORY

Based on potential and nature, the manuscript can be categorized under the following heads:

Original research paper: Such papers are reports of high-level significant original research work.

Review papers: These are concise, significant but helpful and decisive topics for young researchers.

Research articles: These are handled with small investigation and applications

Research letters: The letters are small and concise comments on previously published matters.

5.STRUCTURE AND FORMAT OF MANUSCRIPT

The recommended size of original research paper is less than seven thousand words, review papers fewer than seven thousands words also.Preparation of research paper or how to write research paper, are major hurdle, while writing manuscript. The research articles and research letters should be fewer than three thousand words, the structure original research paper; sometime review paper should be as follows:

Papers: These are reports of significant research (typically less than 7000 words equivalent, including tables, figures, references), and comprise:

(a)Title should be relevant and commensurate with the theme of the paper.

(b) A brief Summary, “Abstract” (less than 150 words) containing the major results and conclusions.

(d) An Introduction, giving necessary background excluding subheadings; objectives must be clearly declared.

(e) Resources and techniques with sufficient complete experimental details (wherever possible by reference) to permit repetition; sources of information must be given and numerical methods must be specified by reference, unless non-standard.

(f) Results should be presented concisely, by well-designed tables and/or figures; the same data may not be used in both; suitable statistical data should be given. All data must be obtained with attention to numerical detail in the planning stage. As reproduced design has been recognized to be important to experiments for a considerable time, the Editor has decided that any paper that appears not to have adequate numerical treatments of the data will be returned un-refereed;

(g) Discussion should cover the implications and consequences, not just recapitulating the results; conclusions should be summarizing.

(h) Brief Acknowledgements.

(i) References in the proper form.

Authors should very cautiously consider the preparation of papers to ensure that they communicate efficiently. Papers are much more likely to be accepted, if they are cautiously designed and laid out, contain few or no errors, are summarizing, and be conventional to the approach and instructions. They will in addition, be published with much less delays than those that require much technical and editorial correction.

The Editorial Board reserves the right to make literary corrections and to make suggestions to improve briefness.

It is vital, that authors take care in submitting a manuscript that is written in simple language and adheres to published guidelines.

Format

Language: The language of publication is UK English. Authors, for whom English is a second language, must have their manuscript efficiently edited by an English-speaking person before submission to make sure that, the English is of high excellence. It is preferable, that manuscripts should be professionally edited.

Standard Usage, Abbreviations, and Units: Spelling and hyphenation should be conventional to The Concise Oxford English Dictionary. Statistics and measurements should at all times be given in figures, e.g. 16 min, except for when the number begins a sentence. When the number does not refer to a unit of measurement it should be spelt in full unless, it is 160 or greater.

Abbreviations supposed to be used carefully. The abbreviated name or expression is supposed to be cited in full at first usage, followed by the conventional abbreviation in parentheses.

Metric SI units are supposed to generally be used excluding where they conflict with current practice or are confusing. For illustration, 1.4 l rather than 1.4 × 10-3 m3, or 4 mm somewhat than 4 × 10-3 m. Chemical formula and solutions must identify the form used, e.g. anhydrous or hydrated, and the concentration must be in clearly defined units. Common species names should be followed by underlines at the first mention. For following use the generic name should be constricted to a single letter, if it is clear.

Structure

All manuscripts submitted to Global Journals Inc. (US), ought to include:

Title: The title page must carry an instructive title that reflects the content, a running title (less than 45 characters together with spaces), names of the authors and co-authors, and the place(s) wherever the work was carried out. The full postal address in addition with the e- mail address of related author must be given. Up to eleven keywords or very brief phrases have to be given to help data retrieval, mining and indexing.

Abstract, used in Original Papers and Reviews:

Optimizing Abstract for Search Engines

Many researchers searching for information online will use search engines such as Google, Yahoo or similar. By optimizing your paper for search engines, you will amplify the chance of someone finding it. This in turn will make it more likely to be viewed and/or cited in a further work. Global Journals Inc. (US) have compiled these guidelines to facilitate you to maximize the web-friendliness of the most public part of your paper.

Key Words

A major linchpin in research work for the writing research paper is the keyword search, which one will employ to find both library and Internet resources.

One must be persistent and creative in using keywords. An effective keyword search requires a strategy and planning a list of possible keywords and phrases to try.

Search engines for most searches, use Boolean searching, which is somewhat different from Internet searches. The Boolean search uses "operators," words (and, or, not, and near) that enable you to expand or narrow your affords. Tips for research paper while preparing research paper are very helpful guideline of research paper.

Choice of key words is first tool of tips to write research paper. Research paper writing is an art.A few tips for deciding as strategically as possible about keyword search:

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• One should start brainstorming lists of possible keywords before even begin searching. Think about the most important concepts related to research work. Ask, "What words would a source have to include to be truly valuable in research paper?" Then consider synonyms for the important words. • It may take the discovery of only one relevant paper to let steer in the right keyword direction because in most databases, the keywords under which a research paper is abstracted are listed with the paper. • One should avoid outdated words.

Keywords are the key that opens a door to research work sources. Keyword searching is an art in which researcher's skills are bound to improve with experience and time.

Numerical Methods: Numerical methods used should be clear and, where appropriate, supported by references.

Acknowledgements: Please make these as concise as possible.

References References follow the Harvard scheme of referencing. References in the text should cite the authors' names followed by the time of their publication, unless there are three or more authors when simply the first author's name is quoted followed by et al. unpublished work has to only be cited where necessary, and only in the text. Copies of references in press in other journals have to be supplied with submitted typescripts. It is necessary that all citations and references be carefully checked before submission, as mistakes or omissions will cause delays.

References to information on the World Wide Web can be given, but only if the information is available without charge to readers on an official site. Wikipedia and Similar websites are not allowed where anyone can change the information. Authors will be asked to make available electronic copies of the cited information for inclusion on the Global Journals Inc. (US) homepage at the judgment of the Editorial Board.

The Editorial Board and Global Journals Inc. (US) recommend that, citation of online-published papers and other material should be done via a DOI (digital object identifier). If an author cites anything, which does not have a DOI, they run the risk of the cited material not being noticeable.

The Editorial Board and Global Journals Inc. (US) recommend the use of a tool such as Reference Manager for reference management and formatting.

Tables, Figures and Figure Legends

Tables: Tables should be few in number, cautiously designed, uncrowned, and include only essential data. Each must have an Arabic number, e.g. Table 4, a self-explanatory caption and be on a separate sheet. Vertical lines should not be used.

Figures: Figures are supposed to be submitted as separate files. Always take in a citation in the text for each figure using Arabic numbers, e.g. Fig. 4. Artwork must be submitted online in electronic form by e-mailing them.

Preparation of Electronic Figures for Publication Even though low quality images are sufficient for review purposes, print publication requires high quality images to prevent the final product being blurred or fuzzy. Submit (or e-mail) EPS (line art) or TIFF (halftone/photographs) files only. MS PowerPoint and Word Graphics are unsuitable for printed pictures. Do not use pixel-oriented software. Scans (TIFF only) should have a resolution of at least 350 dpi (halftone) or 700 to 1100 dpi (line drawings) in relation to the imitation size. Please give the data for figures in black and white or submit a Color Work Agreement Form. EPS files must be saved with fonts embedded (and with a TIFF preview, if possible).

For scanned images, the scanning resolution (at final image size) ought to be as follows to ensure good reproduction: line art: >650 dpi; halftones (including gel photographs) : >350 dpi; figures containing both halftone and line images: >650 dpi.

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Color Charges: It is the rule of the Global Journals Inc. (US) for authors to pay the full cost for the reproduction of their color artwork. Hence, please note that, if there is color artwork in your manuscript when it is accepted for publication, we would require you to complete and return a color work agreement form before your paper can be published.

Figure Legends: Self-explanatory legends of all figures should be incorporated separately under the heading 'Legends to Figures'. In the full-text online edition of the journal, figure legends may possibly be truncated in abbreviated links to the full screen version. Therefore, the first 100 characters of any legend should notify the reader, about the key aspects of the figure.

6. AFTER ACCEPTANCE

Upon approval of a paper for publication, the manuscript will be forwarded to the dean, who is responsible for the publication of the Global Journals Inc. (US).

6.1 Proof Corrections The corresponding author will receive an e-mail alert containing a link to a website or will be attached. A working e-mail address must therefore be provided for the related author.

Acrobat Reader will be required in order to read this file. This software can be downloaded

(Free of charge) from the following website: www.adobe.com/products/acrobat/readstep2.html. This will facilitate the file to be opened, read on screen, and printed out in order for any corrections to be added. Further instructions will be sent with the proof.

Proofs must be returned to the dean at [email protected] within three days of receipt.

As changes to proofs are costly, we inquire that you only correct typesetting errors. All illustrations are retained by the publisher. Please note that the authors are responsible for all statements made in their work, including changes made by the copy editor.

6.2 Early View of Global Journals Inc. (US) (Publication Prior to Print) The Global Journals Inc. (US) are enclosed by our publishing's Early View service. Early View articles are complete full-text articles sent in advance of their publication. Early View articles are absolute and final. They have been completely reviewed, revised and edited for publication, and the authors' final corrections have been incorporated. Because they are in final form, no changes can be made after sending them. The nature of Early View articles means that they do not yet have volume, issue or page numbers, so Early View articles cannot be cited in the conventional way.

6.3 Author Services Online production tracking is available for your article through Author Services. Author Services enables authors to track their article - once it has been accepted - through the production process to publication online and in print. Authors can check the status of their articles online and choose to receive automated e-mails at key stages of production. The authors will receive an e-mail with a unique link that enables them to register and have their article automatically added to the system. Please ensure that a complete e-mail address is provided when submitting the manuscript.

6.4 Author Material Archive Policy Please note that if not specifically requested, publisher will dispose off hardcopy & electronic information submitted, after the two months of publication. If you require the return of any information submitted, please inform the Editorial Board or dean as soon as possible.

6.5 Offprint and Extra Copies A PDF offprint of the online-published article will be provided free of charge to the related author, and may be distributed according to the Publisher's terms and conditions. Additional paper offprint may be ordered by emailing us at: [email protected] .

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Before start writing a good quality Computer Science Research Paper, let us first understand what is Computer Science Research Paper? So, Computer Science Research Paper is the paper which is written by professionals or scientists who are associated to Computer Science and Information Technology, or doing research study in these areas. If you are novel to this field then you can consult about this field from your supervisor or guide.

TECHNIQUES FOR WRITING A GOOD QUALITY RESEARCH PAPER:

1. Choosing the topic: In most cases, the topic is searched by the interest of author but it can be also suggested by the guides. You can have several topics and then you can judge that in which topic or subject you are finding yourself most comfortable. This can be done by asking several questions to yourself, like Will I be able to carry our search in this area? Will I find all necessary recourses to accomplish the search? Will I be able to find all information in this field area? If the answer of these types of questions will be "Yes" then you can choose that topic. In most of the cases, you may have to conduct the surveys and have to visit several places because this field is related to Computer Science and Information Technology. Also, you may have to do a lot of work to find all rise and falls regarding the various data of that subject. Sometimes, detailed information plays a vital role, instead of short information.

2. Evaluators are human: First thing to remember that evaluators are also human being. They are not only meant for rejecting a paper. They are here to evaluate your paper. So, present your Best.

3. Think Like Evaluators: If you are in a confusion or getting demotivated that your paper will be accepted by evaluators or not, then think and try to evaluate your paper like an Evaluator. Try to understand that what an evaluator wants in your research paper and automatically you will have your answer.

4. Make blueprints of paper: The outline is the plan or framework that will help you to arrange your thoughts. It will make your paper logical. But remember that all points of your outline must be related to the topic you have chosen.

5. Ask your Guides: If you are having any difficulty in your research, then do not hesitate to share your difficulty to your guide (if you have any). They will surely help you out and resolve your doubts. If you can't clarify what exactly you require for your work then ask the supervisor to help you with the alternative. He might also provide you the list of essential readings.

6. Use of computer is recommended: As you are doing research in the field of Computer Science, then this point is quite obvious.

7. Use right software: Always use good quality software packages. If you are not capable to judge good software then you can lose quality of your paper unknowingly. There are various software programs available to help you, which you can get through Internet.

8. Use the Internet for help: An excellent start for your paper can be by using the Google. It is an excellent search engine, where you can have your doubts resolved. You may also read some answers for the frequent question how to write my research paper or find model research paper. From the internet library you can download books. If you have all required books make important reading selecting and analyzing the specified information. Then put together research paper sketch out.

9. Use and get big pictures: Always use encyclopedias, Wikipedia to get pictures so that you can go into the depth.

10. Bookmarks are useful: When you read any book or magazine, you generally use bookmarks, right! It is a good habit, which helps to not to lose your continuity. You should always use bookmarks while searching on Internet also, which will make your search easier.

11. Revise what you wrote: When you write anything, always read it, summarize it and then finalize it.

12. Make all efforts: Make all efforts to mention what you are going to write in your paper. That means always have a good start. Try to mention everything in introduction, that what is the need of a particular research paper. Polish your work by good skill of writing and always give an evaluator, what he wants.

13. Have backups: When you are going to do any important thing like making research paper, you should always have backup copies of it either in your computer or in paper. This will help you to not to lose any of your important.

14. Produce good diagrams of your own: Always try to include good charts or diagrams in your paper to improve quality. Using several and unnecessary diagrams will degrade the quality of your paper by creating "hotchpotch." So always, try to make and include those diagrams, which are made by your own to improve readability and understandability of your paper.

15. Use of direct quotes: When you do research relevant to literature, history or current affairs then use of quotes become essential but if study is relevant to science then use of quotes is not preferable.

16. Use proper verb tense: Use proper verb tenses in your paper. Use past tense, to present those events that happened. Use present tense to indicate events that are going on. Use future tense to indicate future happening events. Use of improper and wrong tenses will confuse the evaluator. Avoid the sentences that are incomplete.

17. Never use online paper: If you are getting any paper on Internet, then never use it as your research paper because it might be possible that evaluator has already seen it or maybe it is outdated version.

18. Pick a good study spot: To do your research studies always try to pick a spot, which is quiet. Every spot is not for studies. Spot that suits you choose it and proceed further.

19. Know what you know: Always try to know, what you know by making objectives. Else, you will be confused and cannot achieve your target.

20. Use good quality grammar: Always use a good quality grammar and use words that will throw positive impact on evaluator. Use of good quality grammar does not mean to use tough words, that for each word the evaluator has to go through dictionary. Do not start sentence with a conjunction. Do not fragment sentences. Eliminate one-word sentences. Ignore passive voice. Do not ever use a big word when a diminutive one would suffice. Verbs have to be in agreement with their subjects. Prepositions are not expressions to finish sentences with. It is incorrect to ever divide an infinitive. Avoid clichés like the disease. Also, always shun irritating alliteration. Use language that is simple and straight forward. put together a neat summary.

21. Arrangement of information: Each section of the main body should start with an opening sentence and there should be a changeover at the end of the section. Give only valid and powerful arguments to your topic. You may also maintain your arguments with records.

22. Never start in last minute: Always start at right time and give enough time to research work. Leaving everything to the last minute will degrade your paper and spoil your work.

23. Multitasking in research is not good: Doing several things at the same time proves bad habit in case of research activity. Research is an area, where everything has a particular time slot. Divide your research work in parts and do particular part in particular time slot.

24. Never copy others' work: Never copy others' work and give it your name because if evaluator has seen it anywhere you will be in trouble.

25. Take proper rest and food: No matter how many hours you spend for your research activity, if you are not taking care of your health then all your efforts will be in vain. For a quality research, study is must, and this can be done by taking proper rest and food.

26. Go for seminars: Attend seminars if the topic is relevant to your research area. Utilize all your resources.

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27. Refresh your mind after intervals: Try to give rest to your mind by listening to soft music or by sleeping in intervals. This will also improve your memory.

28. Make colleagues: Always try to make colleagues. No matter how sharper or intelligent you are, if you make colleagues you can have several ideas, which will be helpful for your research.

29. Think technically: Always think technically. If anything happens, then search its reasons, its benefits, and demerits.

30. Think and then print: When you will go to print your paper, notice that tables are not be split, headings are not detached from their descriptions, and page sequence is maintained.

31. Adding unnecessary information: Do not add unnecessary information, like, I have used MS Excel to draw graph. Do not add irrelevant and inappropriate material. These all will create superfluous. Foreign terminology and phrases are not apropos. One should NEVER take a broad view. Analogy in script is like feathers on a snake. Not at all use a large word when a very small one would be sufficient. Use words properly, regardless of how others use them. Remove quotations. Puns are for kids, not grunt readers. Amplification is a billion times of inferior quality than sarcasm.

32. Never oversimplify everything: To add material in your research paper, never go for oversimplification. This will definitely irritate the evaluator. Be more or less specific. Also too, by no means, ever use rhythmic redundancies. Contractions aren't essential and shouldn't be there used. Comparisons are as terrible as clichés. Give up ampersands and abbreviations, and so on. Remove commas, that are, not necessary. Parenthetical words however should be together with this in commas. Understatement is all the time the complete best way to put onward earth-shaking thoughts. Give a detailed literary review.

33. Report concluded results: Use concluded results. From raw data, filter the results and then conclude your studies based on measurements and observations taken. Significant figures and appropriate number of decimal places should be used. Parenthetical remarks are prohibitive. Proofread carefully at final stage. In the end give outline to your arguments. Spot out perspectives of further study of this subject. Justify your conclusion by at the bottom of them with sufficient justifications and examples.

34. After conclusion: Once you have concluded your research, the next most important step is to present your findings. Presentation is extremely important as it is the definite medium though which your research is going to be in print to the rest of the crowd. Care should be taken to categorize your thoughts well and present them in a logical and neat manner. A good quality research paper format is essential because it serves to highlight your research paper and bring to light all necessary aspects in your research.

,1)250$/*8,'(/,1(62)5(6($5&+3$3(5:5,7,1* Key points to remember:

Submit all work in its final form. Write your paper in the form, which is presented in the guidelines using the template. Please note the criterion for grading the final paper by peer-reviewers.

Final Points:

A purpose of organizing a research paper is to let people to interpret your effort selectively. The journal requires the following sections, submitted in the order listed, each section to start on a new page.

The introduction will be compiled from reference matter and will reflect the design processes or outline of basis that direct you to make study. As you will carry out the process of study, the method and process section will be constructed as like that. The result segment will show related statistics in nearly sequential order and will direct the reviewers next to the similar intellectual paths throughout the data that you took to carry out your study. The discussion section will provide understanding of the data and projections as to the implication of the results. The use of good quality references all through the paper will give the effort trustworthiness by representing an alertness of prior workings.

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Writing a research paper is not an easy job no matter how trouble-free the actual research or concept. Practice, excellent preparation, and controlled record keeping are the only means to make straightforward the progression.

General style:

Specific editorial column necessities for compliance of a manuscript will always take over from directions in these general guidelines.

To make a paper clear

· Adhere to recommended page limits

Mistakes to evade

Insertion a title at the foot of a page with the subsequent text on the next page Separating a table/chart or figure - impound each figure/table to a single page Submitting a manuscript with pages out of sequence

In every sections of your document

· Use standard writing style including articles ("a", "the," etc.)

· Keep on paying attention on the research topic of the paper

· Use paragraphs to split each significant point (excluding for the abstract)

· Align the primary line of each section

· Present your points in sound order

· Use present tense to report well accepted

· Use past tense to describe specific results

· Shun familiar wording, don't address the reviewer directly, and don't use slang, slang language, or superlatives

· Shun use of extra pictures - include only those figures essential to presenting results

Title Page:

Choose a revealing title. It should be short. It should not have non-standard acronyms or abbreviations. It should not exceed two printed lines. It should include the name(s) and address (es) of all authors.

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Abstract:

The summary should be two hundred words or less. It should briefly and clearly explain the key findings reported in the manuscript-- must have precise statistics. It should not have abnormal acronyms or abbreviations. It should be logical in itself. Shun citing references at this point.

An abstract is a brief distinct paragraph summary of finished work or work in development. In a minute or less a reviewer can be taught the foundation behind the study, common approach to the problem, relevant results, and significant conclusions or new questions.

Write your summary when your paper is completed because how can you write the summary of anything which is not yet written? Wealth of terminology is very essential in abstract. Yet, use comprehensive sentences and do not let go readability for briefness. You can maintain it succinct by phrasing sentences so that they provide more than lone rationale. The author can at this moment go straight to shortening the outcome. Sum up the study, wi th the subsequent elements in any summary. Try to maintain the initial two items to no more than one ruling each.

Reason of the study - theory, overall issue, purpose Fundamental goal To the point depiction of the research Consequences, including definite statistics - if the consequences are quantitative in nature, account quantitative data; results of any numerical analysis should be reported Significant conclusions or questions that track from the research(es)

Approach:

Single section, and succinct As a outline of job done, it is always written in past tense A conceptual should situate on its own, and not submit to any other part of the paper such as a form or table Center on shortening results - bound background informati on to a verdict or two, if completely necessary What you account in an conceptual must be regular with what you reported in the manuscript Exact spelling, clearness of sentences and phrases, and appropriate reporting of quantities (proper units, important statistics) are just as significant in an abstract as they are anywhere else

Introduction:

The Introduction should "introduce" the manuscript. The reviewer should be presented with sufficient background information to be capable to comprehend and calculate the purpose of your study without having to submit to other works. The basis for the study should be offered. Give most important references but shun difficult to make a comprehensive appraisal of the topic. In the introduction, describe the problem visibly. If the problem is not acknowledged in a logical, reasonable way, the reviewer will have no attention in your result. Speak in common terms about techniques used to explain the problem, if needed, but do not present any particulars about the protocols here. Following approach can create a valuable beginning:

Explain the value (significance) of the study Shield the model - why did you employ this particular system or method? What is its compensation? You strength remark on its appropriateness from a abstract point of vision as well as point out sensible reasons for using it. Present a justification. Status your particular theory (es) or aim(s), and describe the logic that led you to choose them. Very for a short time explain the tentative propose and how it skilled the declared objectives.

Approach:

Use past tense except for when referring to recognized facts. After all, the manuscript will be submitted after the entire job is done. Sort out your thoughts; manufacture one key point with every section. If you make the four points listed above, you will need a

least of four paragraphs.

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Present surroundings information only as desirable in order hold up a situation. The reviewer does not desire to read the whole thing you know about a topic. Shape the theory/purpose specifically - do not take a broad view. As always, give awareness to spelling, simplicity and correctness of sentences and phrases.

Procedures (Methods and Materials):

This part is supposed to be the easiest to carve if you have good skills. A sound written Procedures segment allows a capable scientist to replacement your results. Present precise information about your supplies. The suppliers and clarity of reagents can be helpful bits of information. Present methods in sequential order but linked methodologies can be grouped as a segment. Be concise when relating the protocols. Attempt for the least amount of information that would permit another capable scientist to spare your outcome but be cautious that vital information is integrated. The use of subheadings is suggested and ought to be synchronized with the results section. When a technique is used that has been well described in another object, mention the specific item describing a way but draw the basic principle while stating the situation. The purpose is to text all particular resources and broad procedures, so that another person may use some or all of the methods in one more study or referee the scientific value of your work. It is not to be a step by step report of the whole thing you did, nor is a methods section a set of orders.

Materials:

Explain materials individually only if the study is so complex that it saves liberty this way. Embrace particular materials, and any tools or provisions that are not frequently found in laboratories. Do not take in frequently found. If use of a definite type of tools. Materials may be reported in a part section or else they may be recognized along with your measures.

Methods:

Report the method (not particulars of each process that engaged the same methodology) Describe the method entirely To be succinct, present methods under headings dedicated to specific dealings or groups of measures Simplify - details how procedures were completed not how they were exclusively performed on a particular day. If well known procedures were used, account the procedure by name, possibly with reference, and that's all.

Approach:

It is embarrassed or not possible to use vigorous voice when documenting methods with no using first person, which would focus the reviewer's interest on the researcher rather than the job. As a result when script up the methods most authors use third person passive voice. Use standard style in this and in every other part of the paper - avoid familiar lists, and use full sentences.

What to keep away from

Resources and methods are not a set of information. Skip all descriptive information and surroundings - save it for the argument. Leave out information that is immaterial to a third party.

Results:

The principle of a results segment is to present and demonstrate your conclusion. Create this part a entirely objective details of the outcome, and save all understanding for the discussion.

The page length of this segment is set by the sum and types of data to be reported. Carry on to be to the point, by means of statistics and tables, if suitable, to present consequences most efficiently.You must obviously differentiate material that would usually be incorporated in a study editorial from any unprocessed d ata or additional appendix matter that woul d not be available. In fact, such matter should not be submitted at all except requested by the instructor.

Content

Sum up your conclusion in text and demonstrate them, if suitable, with figures and tables. In manuscript, explain each of your consequences, point the reader to remarks that are most appropriate. Present a background, such as by describing the question that was addressed by creation an exacting study. Explain results of control experiments and comprise remarks that are not accessible in a prescribed figure or table, if appropriate. Examine your data, then prepare the analyzed (transformed) data in the form of a figure (graph), table, or in manuscript form. What to stay away from Do not discuss or infer your outcome, report surroundings information, or try to explain anything. Not at all, take in raw data or intermediate calculations in a research manuscript. Do not present the similar data more than once. Manuscri pt should complement any figures or tables, not duplicate the identical information. Never confuse figures with tables - there is a difference. Approach As forever, use past tense when you submit to your results, and put the whole thing in a reasonable order. Put figures and tables, appropriately numbered, in order at the end of the report If you desire, you may place your figures and tables properly within the text of your results part. Figures and tables If you put figures and tables at the end of the details, make certain that they are visibly distinguished from any attach appendix materials, such as raw facts Despite of position, each figure must be numbered one after the other and complete with subtitle In spite of position, each table must be titled, numbered one after the other and complete with heading All figure and table must be adequately complete that it could situate on its own, divide from text Discussion:

The Discussion is expected the trickiest segment to write and describe. A lot of papers submitted for journal are discarded based on problems with the Discussion. There is no head of state for how long a argument should be. Position your understanding of the outcome visibly to lead the reviewer through your conclusions, and then finish the paper with a summing up of the implication of the study. The purpose here is to offer an understanding of your results and hold up for all of your conclusions, using facts from your research and generally accepted information, if suitable. The implication of result should be visibly described. Infer your data in the conversation in suitable depth. This means that when you clarify an observable fact you must explain mechanisms that may account for the observation. If your results vary from your prospect, make clear why that may have happened. If your results agree, then explain the theory that the proof supported. It is never suitable to just state that the data approved with prospect, and let it drop at that.

Make a decision if each premise is supported, discarded, or if you cannot make a conclusion with assurance. Do not just dismiss a study or part of a study as "uncertain." Research papers are not acknowledged if the work is imperfect. Draw what conclusions you can based upon the results that you have, and take care of the study as a finished work You may propose future guidelines, such as how the experiment might be personalized to accomplish a new idea. Give details all of your remarks as much as possible, focus on mechanisms. Make a decision if the tentative design sufficiently addressed the theory, and whether or not it was correctly restricted. Try to present substitute explanations if sensible alternatives be present. One research will not counter an overall question, so maintain the large picture in mind, where do you go next? The best studies unlock new avenues of study. What questions remain? Recommendations for detailed papers will offer supplementary suggestions. Approach:

When you refer to information, differentiate data generated by your own studies from available information Submit to work done by specific persons (including you) in past tense. Submit to generally acknowledged facts and main beliefs in present tense.

XXI

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Please carefully note down following rules and regulation before submitting your Research Paper to Global Journals Inc. (US):

Segment Draft and Final Research Paper: You have to strictly follow the template of research paper. If it is not done your paper may get rejected.

The major constraint is that you must independently make all content, tables, graphs, and facts that are offered in the paper. You must write each part of the paper wholly on your own. The Peer-reviewers need to identify your own perceptive of the concepts in your own terms. NEVER extract straight from any foundation, and never rephrase someone else's analysis.

Do not give permission to anyone else to "PROOFREAD" your manuscript.

Methods to avoid Plagiarism is applied by us on every paper, if found guilty, you will be blacklisted by all of our collaborated research groups, your institution will be informed for this and strict legal actions will be taken immediately.) To guard yourself and others from possible illegal use please do not permit anyone right to use to your paper and files.

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CRITERION FOR GRADING A RESEARCH PAPER (COMPILATION) BY GLOBAL JOURNALS INC. (US) Please note that following table is only a Grading of "Paper Compilation" and not on "Performed/Stated Research" whose grading solely depends on Individual Assigned Peer Reviewer and Editorial Board Member. These can be available only on request and after decision of Paper. This report will be the property of Global Journals Inc. (US).

Topics Grades

A-B C-D E-F

Clear and concise with Unclear summary and no No specific data with ambiguous appropriate content, Correct specific data, Incorrect form information Abstract format. 200 words or below Above 200 words Above 250 words

Containing all background Unclear and confusing data, Out of place depth and content, details with clear goal and appropriate format, grammar hazy format appropriate details, flow and spelling errors with specification, no grammar unorganized matter Introduction and spelling mistake, well organized sentence and paragraph, reference cited

Clear and to the point with Difficult to comprehend with Incorrect and unorganized well arranged paragraph, embarrassed text, too much structure with hazy meaning Methods and precision and accuracy of explanation but completed Procedures facts and figures, well organized subheads

Well organized, Clear and Complete and embarrassed Irregular format with wrong facts specific, Correct units with text, difficult to comprehend and figures precision, correct data, well Result structuring of paragraph, no grammar and spelling mistake

Well organized, meaningful Wordy, unclear conclusion, Conclusion is not cited, specification, sound spurious unorganized, difficult to conclusion, logical and comprehend concise explanation, highly Discussion structured paragraph reference cited

Complete and correct Beside the point, Incomplete Wrong format and structuring References format, well organized

XXIII

Inde x

A I

Architect · 45 Immittance · 82, 85, 86

Immunomodulation · 21

Intermaxillary · 28

L Bifidobacteria · 22

Bifidobacteriumbifidum · 15 Lactobacilli · 16, 23, 24

Biosurfactant · 22 Lactobacillus · 17, 22

Bonaccorso · 1, 10 Leukocytes · 43, 49, 53

Lithium · 45

M Carboxymethyl · 87

Cephalometric · 25, 26, 27, 29, 30, 32, 33 Macrostructural · 56 Chebowski · 49 Maillefer · 3, 4, 36 Chemiluminescent · 45 Markopoulos · 47, 53 Chemotaxis · 43, 49, 53 Metabolize · 49 Chlorhexidinegluconate · 17 Microorganisms · 15, 16 Chondrogenesis · 57 Misdiagnosis · 35 Circulating · 39, 42, 43, 51 Mouthrinse · 15, 17, 19, 21, 23 Counterclockwise · 2, 8 Mucocutaneous · 39, 47, 51, 53 Craniomaxillofacial · 55 Mutansgrowth · 22 Cyclopentane · 39 Cytoplasmic · 49

D · 72 Nanoc rystals Darolac · 17 · 39, 41, 42, 43, 44, 45, 47, 51 Desquamative Dihydroxyvitamin · 60, 74 O

Oc clusal · 25, 26, 29, 33 E Odontogenic · 35, 37

Orthodontics · 25, 26, 34 Exogenous · 41, 51 Osseointegration · 73, 76, 77, 79 Osteomyelitis · 37 Osteopenia · 49 F Otolaryngology · 82

Otorhinolaryngology · 84 Fatigue · 1, 2, 6, 8, 11, 12, 13 Otoscope · 82 Flexible · 1, 45

Fluoridated · 61, 87, 91

Fluorinex · 87, 89, 90 T

H Thoroughlyinformed · 17

Tureskymodification · 19 Haukoja · 22 Tygesen · 7, 12 Hydroxyapatite · 55, 58, 60, 61, 63, 64, 66, 73, 75, 87, 91

Ultrastructural · 56, 73 Undistinguishable · 17 Undoubtedly · 8 Unsymmetrical · 8

Wavelength · 85

Xylitol · 87, 89

Probioticmouthrinse · 21, 22

Roughnesses · 68

Saccharomyces · 17 Sacchromyces · 22 Schliephake · 66, 76 Seyedmajidi · 49 Simultaneously · 50 Squamous · 37 Stoppenbach · 82, 84, 85, 86 Straightwire · 28 Submandibular · 35 Superimposition · 25, 29

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